Nurse Review - Utilization Management - Growing Team! Apply For a Great Career At Fallon Health!
Company: Fallon Community Health Plan
Posted on: June 14, 2019
Nurse Review - Utilization Management - Growing Team! Apply For a
Great Career At Fallon Health!US-MA-WorcesterJob ID: 5572Type: Full
Time# of Openings: 1Category: NursingFallon Health - Corp
HQOverviewAbout 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 .
Position Overview: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 first level reviewto 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 determination.Responsibilities
- Conduct concurrent and retrospective utilization review for
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.
QualificationsEducation: Graduate from an accredited school of
nursing, or Bachelors (or advanced) degree in nursing------
License: Active and unrestricted licensure as a Registered Nurse in
- 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. PM16
Keywords: Fallon Community Health Plan, Worcester , Nurse Review - Utilization Management - Growing Team! Apply For a Great Career At Fallon Health!, Executive , Worcester, Massachusetts
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