RN Nurse Case Manager (Per Diem)

Mass General Brigham•Newton, MA

1d•Remote

About The Position

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. The essential duties of the Insurance Support-Utilization Case Manager are to act as the department coordinator for all insurance workflows that case managers are responsible for; be the department point person for managing and preventing denials and the department expert for understanding payer rules and regulations. The Insurance support- Utilization Case Manager works closely with care coordination, medical and surgical physicians, nursing staff and other PHS departments that are responsible for billing, compliance, and finance and revenue integrity. Key areas of responsibilities include managing day to day payer communication as it relates to supporting hospital admissions; providing UR to payers as needed; managing complex billing decisions; identifying payer trends; responding to payer denials; interfacing with other departments that impact billing and denials; educating care coordination staff about utilization management issues, government regulations and other things that impact revenue integrity; and providing reports related to UM as needed.

Requirements

Associate's Degree Nursing required or Bachelor's Degree Nursing preferred.
Registered Nurse (RN) License for the State of Massachusetts required.
3+ years of Medical Surgical experience required.
Proficient in Microsoft Office and industry related software programs.
Ability to maintain client and staff confidentiality.

Nice To Haves

Utilization Review (UR) experience strongly preferred.
Knowledge of Healthcare and Managed Care 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.
Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.

Responsibilities

Act as the department coordinator for all insurance workflows that case managers are responsible for.
Be the department point person for managing and preventing denials.
Be the department expert for understanding payer rules and regulations.
Manage day to day payer communication as it relates to supporting hospital admissions.
Provide UR to payers as needed.
Manage complex billing decisions.
Identify payer trends.
Respond to payer denials.
Interface with other departments that impact billing and denials.
Educate care coordination staff about utilization management issues, government regulations and other things that impact revenue integrity.
Provide reports related to UM as needed.