UM Regulatory Nurse Specialist, Health New England

Baystate Health • Springfield, MA

18h • Remote

About The Position

The UM Regulatory Nurse Specialist is responsible for delivering medical or behavioral health utilization management (UM) and coordination of care services to members in compliance with current accreditation requirements and quality standards, and within the scope of the members’ benefit package. Support s the HNE mission by developing partnerships with and providing personal and accountable service to members and providers. Impact s positive health outcomes for members and positive financial outcomes. Keep s abreast of professional standards, new technologies and proactively seek s out new learning. Compliance and Coding : The Nurse Specialist will assist the Utilization Management Department with developing, implementing, and maintaining the compliance program and compliance risk management efforts for Health New England (HNE) as they pertain the Utilization Management and Case/Disease Management. This position will also manage all requirements around coding review for the department . This position works to ensure that HNE operates within the policies, procedures , and regulations set forth by HNE and by state and federal laws, including HIPAA, Medicare, and Medicaid . A comprehensive knowledge of policies and procedures related to state and federal regulations is required . This position will work closely with the HNE Compliance Department who providers guidance, conducts reviews or monitor potential issues noted in the annual risk assessment and/or annual work plan.  This position will operate as a HS liaison with various departmental stakeholders, including Legal, Government Programs, Complaints & Appeals and Quality.

Requirements

• Massachusetts RN license required
• 3-5 years’ experience as a UM Clinical Review Nurse for a Health Plan
• Understanding of the use of medical coding
• Strong critical thinking skills
• Innovative thinker
• Strong analytical and research skills

Nice To Haves

• Certified Professional Coder Certification coding
• Direct experience in Staff Education
• Innovative thinker
• Strong analytical and research skills

Responsibilities

• Pre-authorization review utilizing criteria to determine appropriateness of requested services
• Admission review utilizing criteria to determine appropriateness of inpatient admission
• Concurrent review utilizing criteria to determine appropriateness of continued stay and appropriate level of care
• Retrospective review utilizing criteria to determine appropriateness of requested service/level of care
• Proactive discharge planning to ensure members’ needs are met throughout the continuum of care
• Perform s research to obtain necessary clinical information for decision making
• Ensure s appropriate timeliness , guidelines , and proper notification standards are met
• Assist s members and providers with transition of care, referral management, care coord ination, and benefit management
• Make s appropriate referrals within CSI team as well as to external resources, such as a members PCP to maximize positive member outcomes as per HNE policies and processes
• Contribute s to enhancement of services -existing and new- by participating on workgroups, clinical initiatives, service initiatives, quality initiatives , and others as assigned
• Assist s with creation and revision of departmental Policy & Procedures
• Process es Member and Provider appeals
• Effectively utilize s HNE UM/CM/DM policies and pr ocesses, and electronic systems
• Participat es with off-site visits to in-plan facilities and providers
• D evelops and coordinates general compliance educational activities as directed by the Compliance Department as they relate to Health Services. This includes preparing educational materials for annual compliance training requirements and for smaller informal sessions as directed
• M onitor s and update s SupportPoint as needed
• C oordinate s compliance and regulatory responses with the HNE Compliance Department when addressing filings for MCO as required by Commonwealth of MA, Division of Insurance, Federal Healthcare Administration, and MassHealth , including but not limited to renewal applications for HMO Accreditation, License, and Mental Health Parity certification for Commercial and MassHealth . In addition, the Health Services Compliance Specialist will be responsible for HS participation in the ODAG annual audit as well as the CMS Mock Audit, coordinating reporting and gathering all pertinent documentation and oversight of any necess ary re-training for the HS team

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