Utilization Management Nurse BWH

Mass General Brigham•Boston, MA

1d•Remote

About The Position

The Insurance Support Nurse participates in the timely management of denials that are received in the Care Coordination Department. Through sound knowledge of utilization management, the nurse is able to assess a patient's level of care after review of the medical record. The nurse is a part of the care coordination staff and works closely with care coordination, medical and nursing staff to appeal denied claims and expedite appeal processes and case closure. The nurse works closely with admitting and finance staff, to process denied claims. For newly licensed nurses a Bachelor of Science Degree in Nursing is required.

Requirements

Bachelor's Degree Nursing required
Previous experience in a hospital or health care setting required
Hospital utilization review and medical criteria sets required
Five years medical or surgical staff nurse experience required
Experience with leveling tool criteria required (such as InterQual or Milliman)
Strong clinical assessment skills, excellent interpersonal skills including ability to work collaboratively and cooperatively within a team and internal and external customers.
Strong organizational skills and ability to set priorities.
Ability to compile data from concurrent and retrospective medical review to determine clinical appropriateness, level of care and discharge plan; excellent written and verbal communication skills.
Computer skills.
Knowledge and skills to differentiate levels of care.

Nice To Haves

Can this role accept experience in lieu of a degree? Yes

Responsibilities

Utilizing industry accepted utilization and or medical management criteria and can apply criteria to cases retrospectively to determine appropriateness of admission and days of stay, level of care, and over and under utilization.
Demonstrates working knowledge about different industry criteria sets like Milliman, and InterQual.
Demonstrates in depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs as well as commercial insurances and other types of plans: PPO, HMO, or indemnity.
Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
Assists with the preparations of denial notices given to patients.
Reviews cases retrospectively when requested by finance department to determine if admission relates to continue care for Medicare.
Reviews denial letters and sends letters to other departments if appropriate.
Communicates with attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
Works with physician advisor to write appeal letters for denied care and sends letters to insurance companies.
Documents denials in the BWH/MGB’s Denial Database.
Follows up with insurance companies on claims status for clinical denials.
Expert on observation status and reviews observation patients as assigned.
Assists in the completion of utilization reviews to insurers and intermediaries.
Anticipates and troubleshoots claim and reimbursement issues.
Assists in the review of Medicare reports as assigned.
Participates in BWH and MGB’s Finance projects.
Active Member of the ATO/Denial Committee and UR Committee.
Other duties as assigned.