Utilization Management Nurse, Extended Care Facilities
Job Location:
Somerville, NJ - USA
Yearly Salary:
Posted:
Application Deadline:
Vacancies:
Job Summary
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
Given equity this position will pay somewhere between $90000 to $107000 annually.Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham we are at the forefront of transformation with one of the worlds leading integrated healthcare systems. Together we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.
Our work centers on creating an exceptional member experience a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds experiences and skills.
We are pleased to offer competitive salaries and a benefits package with flexible work options career growth opportunities and much more.
The UMCM will utilize clinical knowledge to analyze assess and render approval decisions determine the need for physician review and complete determinations following physician review. This role is primarily responsible for conducting utilization management reviews for post-acute and extended care services including Skilled Nursing Facility (SNF) Acute Rehabilitation and Long-Term Acute Care Hospital (LTAC) admissions and continued stays. The ideal candidate will have prior authorization and utilization management experience in a managed care setting with experience doing post-acute authorizations which includes SNF (skilled nursing facility) LTAC (long-term acute care) and IPR (inpatient rehabilitation). Strong clinical judgment familiarity with post-acute levels of care and the ability to apply medical necessity criteria to support timely and appropriate coverage decisions are essential for success in this role.
Principal Duties and Responsibilities:
-Ensures post-acute services (rehabilitation skilled nursing long-term acute care home care) are clinically appropriate and aligned with best practices.
-Guides decisions on admission continued stay transfer readiness or discharge.
-Serves as a first-level screening with physician oversight when criteria are not fully met.
-Accounts for patient severity of illness comorbidities and complications.
-Includes objective endpoints for recovery plateau or goal achievement to inform care planning.
-Proficient with Microsoft Word Excel Outlook McKesson InterQual Outlook SharePoint PC based operating system and web-based phone system.
Qualifications
Education
- Associates Degree Nursing required or Bachelors Degree Nursing preferred
Licenses and Credentials
- Massachusetts Registered Nurse (RN) license required
Experience
- Post-acute utilization review experience (SNF Rehab LTAC) UM experience highly preferred
- At least 2-3 years of utilization review experience is highly preferred
- Experience using Interqual or Milliman is highly preferred
- At least 1-2 years of experience in a payer setting is highly preferred
- At least 1-2 years of experience in an acute care setting is highly preferred
Knowledge Skills and Abilities
- Demonstrate Mass General Brigham Health Plans core brand principles of always listening challenging conventions and providing value
- Strong aptitude for technology-based solutions.
- Embrace opportunities to take the complexity out of how we work and what we deliver.
- Listen to our constituents learn and act quickly in our ongoing pursuit of meaningful innovation
- Current in healthcare trends.
- Ability to inject energy when and where its needed.
- Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
- Be accountable for delivering high-quality work. Act with a clear sense of ownership.
- Bring fresh ideas forward by actively listening to and working with employees and the people we serve.
- Communicate respectfully and professionally with colleagues
- Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
Additional Job Details (if applicable)
Working Conditions
- Would need to be available for on call for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire.
- This is a remote role with occasional onsite team meetings in Somerville MA.
Given equity this position will pay somewhere between $90000 to $107000 annually.
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$58656.00 - $142448.80/AnnualGrade
98TEMPEEO Statement:
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.
Required Experience:
IC
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
