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Form of workThe UM RN (Utlilization Management RN) will be working flexible remote - mostly from home but may be required for some in office meetings in Worcester, MA. The schedule is M - F 8 am to 5 pm.
About us:
Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.
Brief summary of purpose:
The UM Nurse uses a multidisciplinary approach to organize, coordinate, monitor, evaluate and modify plans of care and/or service requests, focusing on selected complex medical and psychosocial needs of FH members and their families. The UM Nurse is responsible for assuring the receipt of high quality, cost efficient medical outcomes for enrollees. This role works with Medical Directors, Authorization Coordinators, and Service Coordinators to perform pre-service, concurrent, and retrospective reviews for Acute Hospital and post-acute facility level of utilizing established Care Coordination polices and protocols, Fallon Health benefit criteria, applicable regulatory review criteria and nationally accepted criteria for medical necessity determinations.
Responsibilities- Obtain clinical, functional, and psychosocial information from the medical records on site, through remote electronic access, telephonically or by fax in a collaborative effort with other health care professionals, member and/or family
- Refers cases to medical review according to policy and procedure
- Documents clinical, functional, psychosocial information in the Core System as well as communications regarding the members' care
- Keeps records and submits reports as assigned by the Manager
- Refers high-risk cases to the Case Management Department, Government Services Clinical Programs, Fallon Clinic Care Coordination
- Department and/or other community services according to department protocol
- Collaborates with attending physicians and health care professionals regarding appropriate utilization of medical services
- Completes level of care reviews strictly adhering to regulatory turnaround time guidelines such as, but not limited to, CMS NCQA, and the DOI
- Identifies utilization issues unique to their team assignment and identifies strategies to address/resolve these issues
- Issues regulatory and other letters according to the department policies and procedures.
- Electronic copies of all denial letters and related documents are kept in the Fallon Health core application and/or the organization's security accessed drive(s)
- Acts as a liaison between assigned facilities, members/families, and Fallon Health. Clarify policies/procedures and member benefits as needed. Authorizes services, coordinates care, and ensures timeliness and coordination of healthcare services, in compliance with department and regulatory standards, seeking supplemental services when appropriate or when needed
- Works with Fallon Health providers/support staff and/or members to facilitate cost-effective, quality care
- Requests and obtains relevant clinical information from medical care providers as needed for the clinical review process
- Conducts clinical reviews of retrospective and concurrent Acute Inpatient Hospital and proposed post-Acute level of care requests against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status
- Conducts concurrent Inpatient Hospital and Post-Acute level of care reviews, authorizing continuation of services meeting criteria
- Refers all cases that do not meet medical necessity, benefit eligibility, and network contract status criteria to a physician reviewer for consideration, ensuring the timely review of the referred case
Education
Graduate from an accredited school of nursing, or Bachelors (or advanced) degree in nursing required.
License/Certifications
Active and unrestricted licensure as a Registered Nurse in Massachusetts.
Experience
- A minimum of three to five years clinical experience as a Registered Nurse in a clinical setting required.
- 2 years' experience as a Utilization Management nurse in a managed care payer preferred.
- One year experience as a case manager in a payer or facility setting highly preferred.
- Discharge planning experience highly preferred.
Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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Employment Type: OTHER
