UM Outpatient Clinical Review Nurse, Health New England

Baystate Health • Springfield, MA

11h • Remote

About The Position

The UM Outpatient Clinical Review Nurse c ontributes to the overall success of the Utilization Management department by performing clinical reviews for outpatient , including determining the member’s overall health, reviewing the type of care being delivered, and evaluating medical necessity, in compliance with governing regulations, internal policies, and procedures.

Requirements

• Current MA RN License
• Bachelor's degree preferred and 3-5 years nursing experience
• Knowledge of utilization management, Medicare and Medicaid strongly preferred
• Highly developed critical thinking skills- prior nursing experience ICU or ER
• Computer literacy and ability to navigate through computer systems
• Excellent written and verbal communication skills, including delivering presentations
• Excellent time management skills with the ability to manage multiple priorities
• Ability to manage an assigned caseload independently
• Strong teamwork skills

Responsibilities

• Perfo rms pre-service, concurrent , and retrospective reviews of member s for appropriate care and setting to determine overall health and appropriate level of care , using applicable coverage documents and clinical guidelines
• Collects, documents, and maintains review finding s and actions taken on member medical records in health management systems, according to utilization management policies and guidelines
• Works with healthcare providers to approve medical determinations or provide recommendations based on requested service and review findings
• Collaborates with Medical Directors, when determination to deny a request is indicated
• Assists with providing education to providers on utilization processes to ensure high quality, appropriate care to members
• Collaborates with care management on referral of members, as appropriate
• Performs clinical reviews for member and provider appeals related to outpatient services
• Participates in the weekend call program, as well as flexible work hours, as needed within the department
• Provides input to the Medical Policy Committee regarding the development/updating of medical policies

Benefits

• Excellent Compensation
• High-quality, low-cost medical, dental and vision insurance
• Generous PTO
• Continuing education support and reimbursement
• Wellbeing programs that include but are not limited to mental, physical, and financial health
• Pet, home, auto and personal insurance
• Life insurance
• Reimbursement for a variety of wellbeing activities, included but limited to gym membership and equipment, personal trainer, massage and so much more!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees