Registered Nurse (RN) - Utilization Review
About The Position
Position Summary: The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis. This position integrates national standards for case management scope of services including: Utilization Management services supporting medical necessity and denial prevention; Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient; Compliance with state and federal regulatory requirements, TJC accreditation standards, and Tenet policy; and Education provided to payers, physicians, hospital/office staff, and ancillary departments related to covered services and administration of benefits. Join our dedicated healthcare team where compassion meets innovation! As a Registered Nurse with us, you'll have the opportunity to make a meaningful impact in patients' lives while enjoying a supportive work environment that fosters professional growth and work-life balance. Ready to be a vital part of our mission? Apply today and bring your passion for nursing to a place where it truly matters! At Metrowest Medical Center - Consolidated, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include: Medical, dental, vision, and life insurance 401(k) retirement savings plan with employer match Generous paid time off Career development and continuing education opportunities Health savings accounts, healthcare & dependent flexible spending accounts Employee Assistance program, Employee discount program Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance Note: Eligibility for benefits may vary by location and is determined by employment status MetroWest Medical Center has been serving the community since we opened as the first public medical facility in Framingham in 1893. MetroWest Medical Center is comprised of Framingham Union Hospital and Leonard Morse Hospital, a unique behavioral health specialty center located in Natick dedicated to the mental health of our community. At Framingham Union Hospital, youll find comprehensive health care services for the entire family including 24-hour emergency care, advanced cardiac care, high-tech cancer treatments and advanced maternity care including our Special Care Level IIB nursery and high-risk pregnancy care. MetroWest Medical Center was recognized by the Joint Commission with a Gold Seal of Approval, a symbol of quality that reflects our commitment to meeting performance standards and providing safe and effective patient care. Our skilled cardiac team was recognized as one of Healthgrades Americas 100 best hospitals for Coronary Intervention and ranked among the top 5% in the nation for coronary interventional procedures in 2023. At MetroWest Medical Center, you can grow your career skills and be a vital member of our team dedicated to improving the health of our community. Join us!
Responsibilities
- facilitate effective resource coordination to help patients achieve optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination
- ensuring that care is provided at the appropriate level of care based on medical necessity
- manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis
- Utilization Management services supporting medical necessity and denial prevention
- Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
- Compliance with state and federal regulatory requirements, TJC accreditation standards, and Tenet policy
- Education provided to payers, physicians, hospital/office staff, and ancillary departments related to covered services and administration of benefits
Benefits
- Medical, dental, vision, and life insurance
- 401(k) retirement savings plan with employer match
- Generous paid time off
- Career development and continuing education opportunities
- Health savings accounts, healthcare & dependent flexible spending accounts
- Employee Assistance program, Employee discount program
- Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
No Education Listed
Number of Employees
5,001-10,000 employees
