Utilization Review Manager - Remote - Faulkner
Site: Brigham and Women's Faulkner Hospital, Inc.
Performs the six essential activities of Case Management: Assessment, Planning, Implementation, coordinating, monitoring, and Reassessing through the continuum of care to facilitate a safe, cost-effective transition post-discharge. Performs all aspects of audits and appeals, including the peer-to-peer process.
-Perform utilization review to evaluate for the appropriate level of care and fax all insurance reviews timely to prevent denials.
-Collaborates with appropriate individuals, departments, and payers to ensure appropriateness of admission, continued days of stay, and reimbursement.
-Demonstrates working knowledge of different industry criteria sets like Milliman and InterQual.
-Demonstrates in-depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs, as well as commercial insurances and other types of plans: PPO, HMO, or indemnity.
-Interact with various third-party payers on a daily basis. Fax clinical in payor communication to the right insurer with the right fax number in the right time frame.
-Refer cases not meeting the appropriate level of care to the Physician Advisor or EHR.
-Review for Observation status and make changes as needed. Accurately facilitate all documentation needed for Medicare status change from inpatient to observation (code 44).
-Perform and monitor for quality issues and document in R.L. solutions.
-Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
-Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
-Must be able to function independently in busy environment.
-Coordinate, complete, and track all clinical denials and appeals.
-Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
-Performs other duties as assigned
-Complies with all policies and standardsRemote1153 Centre Street0Per DiemDay (United States of America)2810 Brigham and Women's Faulkner Hospital, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.
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Job Summary
Schedule: Per DiemPerforms the six essential activities of Case Management: Assessment, Planning, Implementation, coordinating, monitoring, and Reassessing through the continuum of care to facilitate a safe, cost-effective transition post-discharge. Performs all aspects of audits and appeals, including the peer-to-peer process.
-Perform utilization review to evaluate for the appropriate level of care and fax all insurance reviews timely to prevent denials.
-Collaborates with appropriate individuals, departments, and payers to ensure appropriateness of admission, continued days of stay, and reimbursement.
-Demonstrates working knowledge of different industry criteria sets like Milliman and InterQual.
-Demonstrates in-depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs, as well as commercial insurances and other types of plans: PPO, HMO, or indemnity.
-Interact with various third-party payers on a daily basis. Fax clinical in payor communication to the right insurer with the right fax number in the right time frame.
-Refer cases not meeting the appropriate level of care to the Physician Advisor or EHR.
-Review for Observation status and make changes as needed. Accurately facilitate all documentation needed for Medicare status change from inpatient to observation (code 44).
-Perform and monitor for quality issues and document in R.L. solutions.
-Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
-Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
-Must be able to function independently in busy environment.
-Coordinate, complete, and track all clinical denials and appeals.
-Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
-Performs other duties as assigned
-Complies with all policies and standards
Qualifications
- Bachelor's Degree in Nursing required
- Massachusetts Registered Nurse License required
- 5 years of Acute Care Nursing required
- 3 year of Utilization Review and Case Management experience preferred
- 4 or more years of Utilization Review and Case Management experience preferred
- 6 or more of Acute Care Nursing preferred
Knowledge, Skills and Abilities
- Staff adheres to all I C.A.R.E. Standards.
- Demonstrates knowledge, skills and abilities to work with various age groups in order to provide a safe discharge plan.
- Must be able to provide care for the patient despite psychosocial, educational, or physical disability.
- Basic computer skills, experience with Excel and Word, and good computation skills.
- Ability to interact and communicate within a diverse community.
- Competent with InterQual Criteria.
- Competent in Utilization Review, appeals, the peer-to-peer process, and Case Management.
- Use critical thinking skills in all interactions and recognize the need to be solution-driven.
- Good negotiating skills with insurance companies and third-party payers.
- Performs all aspects of discharge planning to the right environment of care, timely.
- Proficient in the use of ECare.
Additional Job Details (if applicable)
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$41.36 - $100.00/Hourly
Grade
RN3500
EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
