Case Manager, Per Diem

UMass Memorial Health • Marlborough, MA

9d • $39 - $71

About The Position

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day. Under the supervision of the Director of Case Management, the Case Management/Utilization Review Coordinator is an experienced clinical case management professional with responsibility for monitoring and maintaining appropriate hospital wide utilization review. Combines clinical, business and regulatory knowledge and skill to ensure appropriate utilization of care, promote optimal billing, insurance benefit use and regulatory compliance and prevent significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Collaborates with physician, case managers, revenue cycle personnel and payers to appeal denials. Performs activities related to the utilization management process, including conducting a denial appeals process that includes monitoring for patterns and trends and maximizing reimbursement within regulatory requirements. Works directly with Case Management team to ensure that clinical operations related to care leveling are timely and accurate. Reviews the work of Case Managers related to Utilization Review and makes determination of appropriate level of care based on clinical knowledge and judgment as a first level reviewer. Identifies opportunities for improved documentation of Utilization Review assessment and maintains responsibility for follow through throughout the patient hospital stays. Maintains responsibility for teaching and assessing competency of Case Management staff related to level of care applications.

Requirements

• Current Massachusetts licensure of RN
• Graduate of an accredited school of nursing.
• BS required
• Minimum 7 -10 years relevant experience including UR/ Case management in the acute care setting.
• Expert working knowledge of all applicable level of care criteria applications-both written and electronic
• Expert in InterQual criteria-maintains level of expertise to be hospital wide trainer
• Comprehensive proficiency the case management role, including direct patient interaction and care planning
• Expert knowledge of current reimbursement models: Commercial, managed care, Medicare, Public Assistance.
• Excellent interpersonal communication and negotiation skills with physicians, payers and peers.
• Ability to engage and educate colleagues regarding utilization, regulatory and compliance issues.
• Ability to work independently with excellent organizational skills and make decisions objectively.
• Strong analytic, data management and computer skills.
• Technical writing ability for appeal letters and reports.
• Analytical abilities to aggregate and report findings and to assist in obtaining solutions to problems.
• Must be able to work independently and prioritize work.
• Must be able to manage multiple priorities.

Nice To Haves

• Certification in Case Management, Billing/Coding preferred

Responsibilities

• Maintains responsibility for the coordination and submission of appeals to third party payers within allotted timeframes to prevent fiscal penalties
• Is the key contact person for all Medicare RAC denials and processes each denial following the established framework.
• Meets with the Case Managers to review the medical record to gather missing supportive documentation to strengthen the appeals process.
• Maintains dialogue with payers about disputed claims and maintains documentation of ongoing efforts for each disputed claim.
• Assists in the writing of draft appeal letters and prepares and edits the final documents prior to submission to the third-party payer.

What This Job Offers

• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees