The Utilization Review RN Care Manager (CM) focuses on ensuring accurate and timely utilization review of the hospital medical surgical and maternal child health inpatient population. Utilization Review includes the process of applying accepted utilization standards and or nationally accepted medical necessity criteria to the clinical information available in the EHR and communicating required clinical information to the payors for appropriate reimbursement to the hospital. The CM seeks out educational and self-development opportunities related to utilization review, healthcare reimbursement, and other pertinent areas.

Essential Functions:

• Application of accepted utilization standards and or nationally accepted medical necessity criteria to all admitted patients in the medical surgical and maternal child health areas of the hospital to confirm correct level of care.

• Timely transmission of clinical information to the payor for review

• Track and send updated clinical reviews for concurrent stay or for consideration of correct level of care as required/requested by payor

• Completes daily continued stay reviews on commercial observation level of care patients for assessment of inpatient level of care

• Contribute to the education of RN CMs and MDs regarding level of care criteria, acute care stay through the sharing of information

• Utilizing accepted utilization standards and or nationally accepted medical necessity criteria help to determine appropriateness of admission, level of care, length of stay and over and under utilization.

• Act as a resource to nurse CMs and provider physicians for questions regarding utilization management

• Establish positive working relationships with payor CM

• Participate in medical/utilization management activities for those patients whose health plan has delegated medical management to the Newton Wellesley Physician Hospital Organization.

• Ensures level of care changes are completed with accurate event management entry inclusive of communication with patient access to proce

• Protects the patient health record by transmitting only required information to correct destination

• Builds an understanding of the denials process and how it is managed with ability to manage the process if needed

• Reviews and manages Medicare one day stays in collaboration with Insurance Support UR nurse and Physician Advisors.

• Other duties as determined by the manager/director of the department.

Quality/Performance Improvement:

• Identify opportunities to improve efficient throughput and accurate UM.

• Under the direction of the Care Coordination Manager, work collaboratively with identified department leads to provide education and effect process change/quality improvement.

Regulatory Compliance and JCAHO Accreditation

• Demonstrates understanding and compliance with applicable standards, e.g. Interqual criteria

• Participates in on site visits or mock surveys.

• Takes responsibility for updating one's knowledge of the National Patient Safety Goals and other patient care related JCAHO standards.

• Demonstrates knowledge about government regulations related to patient rights, confidentiality, and discharge planning.

Other Dutie

• Collaborate with physicians, case managers, revenue cycle personnel, contracting and payers to identify ways to prevent clinical denials.

• Participate in Revenue Cycle, Denials, Billing Compliance and Utilization Review Committees/meetings.

• Attend external meetings that relate to UR, insurance reforms, innovative payment models, etc.

• Demonstrate clear and accurate understanding of all routinely accepted insurance plans including Medicare, Medicaid, Medicare Advantage plans as well as commercial insurances.

• Refer appropriate outlier patient cases to the Physician Advisors and/or Department or Service Chiefs in accordance with departmental policies and procedures.

• Participates and/or carries out other duties as assigned or requested.

Qualifications

• Current licensure as a Registered Nurse in the Commonwealth of Massachusett

• Evidence of continued education and professional development. CCM or ACMA certification preferred

Experience

• Prior experience in the following areas:

o general acute care hospital experience, 3 years minimum

o focused acute care utilization review, minimum one year experience required

o quality improvement

• Previous acute care hospital care coordination/discharge planning required

EEO Statement

Mass General Brigham is an Equal Opportunity Employer & by embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law.