Case Manager (on site), Denials and Appeals, 30 Hours (Weekends)

BMC Software•Boston, MA

3d•$38 - $75•Onsite

About The Position

POSITION SUMMARY: The UM/CM RN will be responsible for review of potential transfers to the BMC System for tertiary care, in conjunction with the multidisciplinary care team, utilizing medical necessity screening tools to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay. This nurse secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required and follows the UR process, in addition to the pre-denial process as defined in the attached job description and in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review. Position: Case Manager (on site) Department: Denials and Appeals Schedule: 30 Hours (Weekends) Weekend hours, in addition to one 10 hour shift on Monday or Friday ESSENTIAL RESPONSIBILITIES / DUTIES: Utilizing a collaborative process, the care manager will assess, plan, implement, monitor, and evaluate the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes. The care manager helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the patient and the reimbursement source. This care manager is dedicated to handle the increased volume and to support the overall care management process and the department. JOB REQUIREMENTS EDUCATION: Graduate of an accredited BS Program in Nursing CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED: Licensed to practice as a Registered Nurse in the commonwealth of Massachusetts CCM or related certification attained within 24 months from the hire date is preferred EXPERIENCE 3-5 years of diversified clinical experience is required A minimum of 2 years of previous experience involving judgment and decision making, preferably in a utilization management/case management position KNOWLEDGE AND SKILLS: Extensive background and knowledge of current medical/surgical patterns of practice. Medical terminology and standard medical abbreviations. Managed care concepts, the various health care delivery systems Methods for assessing an individual are level of physical/mental impairment, understanding of the physical and psychological characteristics of illness, and understanding of expected treatment. Confidentiality issues and the legal and ethical issues pertaining to them. ICD-9 and CPT nomenclature and the ability to interpret and convert this information, as applicable. Knowledge of benefits and various plan contracts, eligibility issues and requirements. Role and functional responsibilities of case management professional; case management program philosophy and purpose within Managed Care Program Excellent interpersonal, verbal and written communication and negotiations skills Strong analytical, data management and PC skills Compensation Range: $38.05- $75.33 This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, and licensure/certifications directly related to position requirements. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), contract increases, Flexible Spending Accounts, 403(b) savings matches, earned time cash out, paid time off, career advancement opportunities, and resources to support employee and family wellbeing. Equal Opportunity Employer/Disabled/Veterans According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment. We do not ask individuals to purchase equipment for or prior to employment. Working at Boston Medical Center is more than a job. It’s a chance to make a difference as part of our mission to provide exceptional and equitable care to all. As a nationally-recognized leader in health equity, nursing, initiatives to combat climate change, and many other areas, BMC is dedicated to improving the health of our community in Boston and beyond. BMC’s mission to provide exceptional care without exception extends to our employees, and we have been recognized as a top employer and best place to work. A strong sense of teamwork and support for our staff are the bedrock of BMC, as we know that we can only provide exceptional care to patients when our staff are cared for too. Boston Medical Center is an equal employment/affirmative action employer. We ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic. If you need accommodation for any part of the application process because of a medical condition or disability, please send an e-mail to [email protected] or call 617-638-8582 to let us know the nature of your request. Boston Medical Center participates in the Electronic Employment Verification Program. As an E-Verify employer, prospective employees of BMC must complete a background check before beginning their employment at the hospital. BMC requires all staff to be vaccinated against COVID-19 and flu, as well as receive a booster dose of the COVID-19 vaccine. According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment. We do not ask individuals to purchase equipment for or prior to employment. To avoid becoming a victim of an employment offer scam, please follow these tips from the FTC: FTC Tips

Requirements

Graduate of an accredited BS Program in Nursing
Licensed to practice as a Registered Nurse in the commonwealth of Massachusetts
3-5 years of diversified clinical experience is required
A minimum of 2 years of previous experience involving judgment and decision making, preferably in a utilization management/case management position
Extensive background and knowledge of current medical/surgical patterns of practice.
Medical terminology and standard medical abbreviations.
Managed care concepts, the various health care delivery systems
Methods for assessing an individual are level of physical/mental impairment, understanding of the physical and psychological characteristics of illness, and understanding of expected treatment.
Confidentiality issues and the legal and ethical issues pertaining to them.
ICD-9 and CPT nomenclature and the ability to interpret and convert this information, as applicable.
Knowledge of benefits and various plan contracts, eligibility issues and requirements.
Role and functional responsibilities of case management professional; case management program philosophy and purpose within Managed Care Program
Excellent interpersonal, verbal and written communication and negotiations skills
Strong analytical, data management and PC skills

Nice To Haves

CCM or related certification attained within 24 months from the hire date is preferred

Responsibilities

The UM/CM RN will be responsible for review of potential transfers to the BMC System for tertiary care, in conjunction with the multidisciplinary care team, utilizing medical necessity screening tools to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay.
This nurse secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required and follows the UR process, in addition to the pre-denial process as defined in the attached job description and in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review.
Utilizing a collaborative process, the care manager will assess, plan, implement, monitor, and evaluate the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes.
The care manager helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the patient and the reimbursement source.
This care manager is dedicated to handle the increased volume and to support the overall care management process and the department.