Utilization Review Manager - Remote - Faulkner

Mass General Brigham•Boston, MA

5d•$41 - $100•Remote

About The Position

This role performs the essential activities of Case Management, including Assessment, Planning, Implementation, coordinating, monitoring, and Reassessing through the continuum of care to facilitate a safe, cost-effective transition post-discharge. The position also performs all aspects of audits and appeals, including the peer-to-peer process. The Utilization Review Manager evaluates for the appropriate level of care, faxes insurance reviews timely to prevent denials, and collaborates with various individuals, departments, and payers to ensure the appropriateness of admission, continued days of stay, and reimbursement. This role requires a working knowledge of industry criteria sets like Milliman and InterQual, as well as an in-depth understanding of various insurance plans including Medicare, Medicaid, other entitlement programs, and commercial insurances (PPO, HMO, indemnity). The manager will interact with third-party payers daily, faxing clinical information and payor communications accurately and within the required timeframe. Cases not meeting the appropriate level of care are referred to the Physician Advisor or EHR. The role also involves reviewing for Observation status, facilitating documentation for Medicare status changes, monitoring for quality issues, and serving as a resource to staff and physicians regarding denial of care processes. Retrospective reviews may be conducted for the finance department to determine if admissions relate to continued care for Medicare. The position requires the ability to function independently in a busy environment, coordinate, complete, and track all clinical denials and appeals, and communicate with attending physicians and care coordination nurses regarding denials. Other duties as assigned and compliance with all policies and standards are also required.

Requirements

Bachelor's Degree in Nursing required
Massachusetts Registered Nurse License required
5 years of Acute Care Nursing required
Basic computer skills, experience with Excel and Word, and good computation skills.
Ability to interact and communicate within a diverse community.
Competent with InterQual Criteria.
Competent in Utilization Review, appeals, the peer-to-peer process, and Case Management.
Use critical thinking skills in all interactions and recognize the need to be solution-driven.
Good negotiating skills with insurance companies and third-party payers.
Performs all aspects of discharge planning to the right environment of care, timely.

Nice To Haves

3 year of Utilization Review and Case Management experience preferred
4 or more years of Utilization Review and Case Management experience preferred
6 or more of Acute Care Nursing preferred
Demonstrates knowledge, skills and abilities to work with various age groups in order to provide a safe discharge plan.
Must be able to provide care for the patient despite psychosocial, educational, or physical disability.
Proficient in the use of ECare.

Responsibilities

Perform utilization review to evaluate for the appropriate level of care and fax all insurance reviews timely to prevent denials.
Collaborates with appropriate individuals, departments, and payers to ensure appropriateness of admission, continued days of stay, and reimbursement.
Interact with various third-party payers on a daily basis. Fax clinical in payor communication to the right insurer with the right fax number in the right time frame.
Refer cases not meeting the appropriate level of care to the Physician Advisor or EHR.
Review for Observation status and make changes as needed. Accurately facilitate all documentation needed for Medicare status change from inpatient to observation (code 44).
Perform and monitor for quality issues and document in R.L. solutions.
Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
Coordinate, complete, and track all clinical denials and appeals.
Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
Performs other duties as assigned
Complies with all policies and standards