Case Manager, Denials and Appeals, 40 Hours (Days)

BMC Software•Boston, MA

3d•$38 - $75

About The Position

The UM 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 SUMMARY: 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.

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

review of potential transfers to the BMC System for tertiary care
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
secure 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
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
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
handle the increased volume and to support the overall care management process and the department