Nurse Review-Utilization Management
Company: Fallon Health
Posted on: March 28, 2020
About Fallon Health: Founded in 1977, Fallon Health is a leading
health care services organization that supports the diverse and
changing needs of those we serve. In addition to offering
innovative health insurance solutions and a variety of Medicaid and
Medicare products, we excel in creating unique health care programs
and services that provide coordinated, integrated care for seniors
and individuals with complex health needs. Fallon has consistently
ranked among the nation's top health plans, and is accredited by
the National Committee for Quality Assurance for its HMO, Medicare
Advantage and Medicaid products. For more information, visit
www.fallonhealth.org. Position Overview:The UM/UR 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/UR 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 first level review
to pre-certify elective services, procedures and tests utilizing
established Care Coordination polices and protocols, Fallon Health
benefit criteria, applicable regulatory review criteria and
nationally accepted criteria for medical necessity
- Conduct concurrent and retrospective utilization review for
outpatient, inpatient, observation or SNF services.
- Oversee utilization management decisions completed by Senior
Nurse Case Managers to ensure decisions are appropriate and
identify and implement corrective action as needed.
- Conducts clinical reviews of proposed services against
appropriate criteria/guidelines to determine medical necessity,
benefit eligibility, and network contract status.
- Work with Medical Directors, Program Leadership and Fallon
Health Provider Relations to identify and mitigate facility
barriers associated with the ability to make timely decisions.
- Identify, align and utilize health plan and community resources
that impact high-risk/high cost care.
- Act as 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.
- Assess enrollee needs and monitor progress toward goals at all
times, communicating findings and status with members of the
enrollee's primary care team.
- Ensure optimal delivery of safe quality health care to members,
while maximizing resources and containing costs, and facilitate
continual patient-centered and outcome-driven health performance
- Create contingency plans to anticipate treatment and service
complications, while ensuring that the enrollee attains
- Review enrollees with the Medical Directors and Primary Care
Teams and advocates for Administration Exception considerations as
- Facilitate communications between the facility, providers, and
the PCT in order to effect and influence a safe and effective
discharge plan and care plan for the enrollee. Education: Graduate
from an accredited school of nursing, or Bachelors (or advanced)
degree in nursing------ License: 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. JT18
Keywords: Fallon Health, Worcester , Nurse Review-Utilization Management, Executive , Worcester, Massachusetts
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