Utilization Management Nurse (RN)
Company: Harbor Health Services
Location: Brockton
Posted on: September 19, 2023
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Job Description:
Offering a $5000. Sign On Bonus!*
Harbor Health Services is an innovative, growing, mission-based
organization that lives, serves and collaborates with our community
members to achieve our mission to help individuals reach their full
potential through access to local, affordable services that promote
health. Harbor provides medical, behavioral health, dental, and
support services to more than 34,000 patients in Boston, the South
Shore, and Cape Cod. In addition, Harbor Health operates two Elder
Service Plan Programs of All-Inclusive Care for the Elderly, a
program that allows frail elders to live in their homes and
communities. Our Elder Service Plan has two medical and day centers
in Mattapan and Brockton, MA and cares for more than 450
participants. We are currently seeking a talented Utilization
Management Nurse to join our care teams at the Elder Service
Plan.
Harbor Health offers a comprehensive Benefits package including
Health, Dental and Vision Insurance, generous Paid Time Off (PTO)
plus 11 additional paid holidays and much more! Come join our great
Elder Service Plan team!
Role:
Under the general direction of the Manager of Utilization
Management and in collaboration with the Care Coordinators, the
Utilization Management Nurse (UM RN) provides care coordination for
a participant's hospital, long term acute care (LTAC), acute
rehabilitation hospital, psychiatric or skilled nursing facility
(SNF) stay. Working with the Interdisciplinary Care Team (IDT), the
UM RN monitors the length of stay (LOS), the appropriate
utilization of care, promotes quality, obtains clinical review, and
plans/implements a participant's discharge.
Responsibilities:
Responsible for the evaluation of the medical necessity of
continuing acute inpatient or psychiatric stays, LTAC, acute
rehabilitation and skilled nursing stays utilizing a defined
criteria set.
Utilizes clinical skills to telephonically provide and facilitate
utilization review, continued stay reviews and utilization
management of all cases based on clinical experience and recognized
guidelines.
Obtains the information necessary to assess a participant's
clinical condition, identifies ongoing clinical care needs and
ensures that participants receive services in the most optimal
setting to effectively meet their needs.
Collaborates with ESP interdisciplinary teams regarding management
of members not meeting continuing stay criteria.
Anticipates member's post-discharge needs, managing transition of
care or referring to Care Coordinator when appropriate.
Maintains mandated timeframes, including those related to second
level appeals.
Uses Patient Ping (a real-time notification system that provides an
alert when patients receive care in the ED, hospital or post-acute
setting) to track participant disposition and work with providers
to establish necessity of emergency room transfers.
Assists with clinical tasks/assignments as needed.
Requirements:
Bachelor's Degree in Nursing required
Current, valid, and unrestricted MA Registered Nurse (R.N.) license
and current BLS Certification required
Minimum of 2-3 years of acute care clinical nursing experience
required
Minimum of 3 years of recent experience in Utilization Review /
Utilization Management preferred
1-2 years of experience at a health plan or other Managed Care
Organization (HMO/TPA/IPA/SCO, etc.) preferred
Experience using MCG/Milliman/InterQual criteria for medical
necessity, setting and level of care, and concurrent patient
management preferred
Basic Computer skills to include Microsoft Word, Excel, database
use, and data entry
Must be able to travel between two or more sites and to outside
contract agencies in a timely manner as needed
All qualified applicants will receive consideration for employment
without regard to race, color, religion, sex, sexual orientation,
gender identity, national origin, disability or veteran status.
*$5000. Sign On Bonus offered, $2500 on hire and $2500 after 90
days in good standing, former employees of HHSI not eligible.
Keywords: Harbor Health Services, Brockton , Utilization Management Nurse (RN), Executive , Brockton, Massachusetts
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