Utilization Review RN- Hospital Case Management

Baystate Health • Springfield, MA

9d • Onsite

About The Position

Baystate Health is seeking a Hospital Utilization Review RN to join their growing healthcare teams. The Utilization Review RN is a registered professional nurse responsible for the coordination of care, quality, and financial outcomes for a designated population of patients. This role coordinates the use of Baystate Health resources to ensure patients receive optimal quality of care and service. The UR RN researches and responds to all medical and behavioral health appeal inquiries and requests in accordance with contractual, account, policy, and accreditation requirements. They conduct admission and concurrent reviews to obtain certification, and facilitate and coordinate with internal and external customers proactively to bring reviews/appeals to satisfactory resolution. This role collaborates with payers through ongoing written and verbal communication to optimize reimbursement potential for Baystate Franklin Medical Center, coordinates the resolution of patient complaints regarding questionable and/or inappropriate charges, adheres to system and department compliance policies and any applicable laws and regulations, and provides high-quality customer service.

Requirements

• Current Massachusetts Registered Nurse (RN) license
• 3-5 years acute care clinical nursing experience or inpatient Case Management experience required
• Experience in utilization review process and utilization management strongly preferred
• Diploma in Nursing

Nice To Haves

• BSN preferred

Responsibilities

• Coordination of care, quality, and financial outcomes for a designated population of patients.
• Coordinate use of BH resources to assure that patients are provided optimal quality of care and service.
• Research and respond to all medical and behavioral health appeal inquiries and requests, in accordance with contractual, account, policy and accreditation requirements.
• Conduct admission and concurrent reviews to obtain certification.
• Facilitate and coordinate with internal and external customers in a proactive manner to bring review/appeal to satisfactory resolution.
• Collaborate with payers through ongoing written and verbal communication to optimize the reimbursement potential for Baystate Franklin Medical Center.
• Coordinate resolution of patient complaints regarding questionable and/or inappropriate charges.
• Adhere to system and department compliance policies and any applicable laws and regulations.
• Provide high quality customer service.

Benefits

• Medical, dental, and vision coverage, including local Health New England plans.
• Tuition assistance, CEUs, and professional development opportunities.
• Clinical advancement, leadership development, and internal career opportunities.
• Career options across Baystate Health hospitals, practices, and services throughout western Massachusetts.
• Retirement savings and employer match.
• Generous PTO for eligible employees.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree