Utilization Management Nurse BWH
Job Description
Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Job Summary
Staff Nurse - 40hr Variable Day - BWH Utilization ManagementThe 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.
Does this position require Patient Care? No
Essential Functions
- Utilization Management
Collaborates with appropriate individuals, departments and payers to ensure appropriateness of admission, continued days of stay and reimbursement.
1. 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.
2. Demonstrates working knowledge about different industry criteria sets like Milliman, and InterQual.
3. 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.
4. Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
5. Assists with the preparations of denial notices given to patients.
6. Reviews cases retrospectively when requested by finance department to determine if admission relates to continue care for Medicare.
- Denial Management
Coordinates the filing of appeals for clinical denials and works with other departments to ensure payment for care provided.
1. Reviews denial letters and sends letters to other departments if appropriate.
2. Communicates with attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
3. Works with physician advisor to write appeal letters for denied care and sends letters to insurance companies.
4. Documents denials in the BWH/MGB’s Denial Database.
5. Follows up with insurance companies on claims status for clinical denials.
- Team Work
Assists with variety of functions and responsibilities of care coordination department to ensure that all state and federal mandates are followed. Participates in the ongoing evaluation of practice patterns and systems, support efforts to improve quality, cost and satisfaction outcomes.
1. Expert on observation status and reviews observation patients as assigned.
2. Assists in the completion of utilization reviews to insurers and intermediaries.
3. Anticipates and troubleshoots claim and reimbursement issues.
4. Assists in the review of Medicare reports as assigned.
5. Participates in BWH and MGB’s Finance projects.
6. Active Member of the ATO/Denial Committee and UR Committee.
7. Other duties as assigned.
Qualifications
Education
Bachelor's Degree Nursing required
Can this role accept experience in lieu of a degree?
Yes
Licenses and Credentials
Massachusetts Registered Nurse
Experience
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)
Knowledge, Skills and Abilities
- 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.
Additional Job Details (if applicable)
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$41.71 - $105.65/Hourly
Grade
MNA333
EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.