Utilization Review Manager - Remote - Faulkner

Mass General Brigham•Jamaica Plain, MA

3d•Remote

About The Position

Performs the six essential activities of Case Management: Assessment, Planning, Implementation, coordinating, monitoring, and Reassessing through the continuum of care to facilitate a safe, cost-effective transition post-discharge. Performs all aspects of audits and appeals, including the peer-to-peer process. This role involves performing utilization review to evaluate for the appropriate level of care and faxing all insurance reviews timely to prevent denials. The manager collaborates with appropriate individuals, departments, and payers to ensure the appropriateness of admission, continued days of stay, and reimbursement. Demonstrates working knowledge of different industry criteria sets like Milliman and InterQual, as well as an in-depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs, and commercial insurances (PPO, HMO, indemnity). The role requires daily interaction with various third-party payers, including faxing clinical information and payor communication to the correct insurer within the right timeframe. Cases not meeting the appropriate level of care are referred to the Physician Advisor or EHR. The position also involves reviewing for Observation status and making necessary changes, accurately facilitating all documentation for Medicare status changes from inpatient to observation (code 44). Quality issues are performed and monitored, and documented in R.L. solutions. The manager serves as a resource to staff and physicians for questions about denial of care processes for Medicare, Medicaid, or other insurances. Retrospective case reviews are conducted when requested by the finance department to determine if admission relates to continued care for Medicare. The role requires the ability to function independently in a busy environment, coordinate, complete, and track all clinical denials and appeals. Communication with the attending physician and care coordination nurse regarding denial of care notifications is essential to understand patient care needs. Other duties as assigned and compliance with all policies and standards are expected.

Requirements

Bachelor's Degree in Nursing required
Massachusetts Registered Nurse License 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.

Nice To Haves

4 or more years of Utilization Review and Case Management experience preferred
6 or more of Acute Care Nursing preferred

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.
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 all aspects of discharge planning to the right environment of care, timely.