Medicare Utilization Management Nurse

Mass General Brigham•Somerville, MA

6d•Remote

About The Position

The Medicare UM Case Manager, RN performs utilization management activities primarily for Medicare Advantage, including review of authorizations for home care, high tech radiology, outpatient, inpatient, and post-acute services. The Medicare UMCM reviews the medical necessity of authorization requests using NCD, LCD, Medicare Benefit Policy Manual, medical policies, and InterQual criteria.

Requirements

Associate's Degree Nursing required; Bachelor's Degree Nursing preferred
Massachusetts Registered Nurse license required
Basic Life Support [BLS Certification] Certification preferred
At least 2-3 years of utilization management strongly preferred
Experience applying National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and Medicare Benefit Policy Manual preferred
InterQual experience preferred
Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
Ability to establish strong rapport and relationships with patients and staff.
Proficient in Microsoft Office and industry-related software programs.
Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
Ability to maintain client and staff confidentiality.
Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
Knowledge of Healthcare and Managed Care preferred.