WorcesterRecruiter Since 2001
the smart solution for Worcester jobs

Nurse Review - Utilization Management - Growing Team! Apply For a Great Career At Fallon Health!

Company: Fallon Community Health Plan
Location: Worcester
Posted on: June 14, 2019

Job Description:

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 improvement activities.
  • Create contingency plans to anticipate treatment and service complications, while ensuring that the enrollee attains pre-determined outcomes.
  • Review enrollees with the Medical Directors and Primary Care Teams and advocates for Administration Exception considerations as appropriate.
  • 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 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. PM16 PI110704881

Keywords: Fallon Community Health Plan, Worcester , Nurse Review - Utilization Management - Growing Team! Apply For a Great Career At Fallon Health!, Executive , Worcester, Massachusetts

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category

Other Executive Jobs

Senior Desktop Management Engineer
Description: NOTES Starting salary will be commensurate with professional experience. This requisition will remain open until filled however, first consideration will be given to those applicants that apply within (more...)
Company: Massachusetts court system
Location: Boston
Posted on: 06/21/2019

Health Services Care Manager
Description: As a Case Manager you will provide assistance to low income elders and adults living with disabilities so that they are able to continue to live independently in the community.
Company: Mystic Valley Elder Services
Location: Malden
Posted on: 06/21/2019

SAP Sales Distribution Manager
Description: A career in our SAP Supply Chain and Operations practice, within SAP Consulting services, will provide you with the opportunity to help our clients maximise the value of their SAP investment with offerings (more...)
Company: PwC
Location: Boston
Posted on: 06/21/2019

Manager, Solutions Consulting
Description: br Overview br br br Due to internal growth, LogMeIn is hiring a Solutions Consulting Manager who will manage a team of highly skilled and dedicated pre-sales Solutions Consultants in support (more...)
Company: LogMeIn
Location: Boston
Posted on: 06/21/2019

Description: Pulse Healthcare is currently seeking Travel Nurses for multiple positions in locations throughout the United States br Start Date: 07/08/2019 br Duration: 91 days br City: Cambridge br State: (more...)
Company: Pulse Healthcare Services
Location: Cambridge
Posted on: 06/21/2019

Director of IT
Description: BACKGROUND Home Market Foods HMF is a dynamic enterprise that has become the market leader in a number of prepared meat-based meal and snack categories. The company has grown substantially across its (more...)
Company: Home Market Foods
Location: Norwood
Posted on: 06/21/2019

Risk Management Examiner I
Description: All applicants should attach a cover letter and resume to their online submission for this position. The Division of Banks is currently accepting applications for the position of Risk Management Examiner (more...)
Company: State of Massachusetts
Location: Boston
Posted on: 06/21/2019

Cyber Oracle Cloud and EBS Security & Controls - Manager
Description: Are you interested in working in a dynamic environment that offers opportunities
Company: Deloitte
Location: Boston
Posted on: 06/21/2019

Director of Human Resources
Description: Job Summary Luxury in the heart of Harvard Square What an exciting opportunity to join this phenomenal team and continue with the culture of nurturing superior guest service and associate engagement. (more...)
Company: Interstate Hotels & Resort
Location: Cambridge
Posted on: 06/21/2019

Patient Care Director - Taunton
Description: KEY RESPONSIBILITIES:Resource AllocationFiscal ResponsibilityPrepares operating and capital budget, meets or is under expense targets and where applicable, revenue projections.Conserves organizational (more...)
Company: New England Sinai Hospital
Location: Taunton
Posted on: 06/21/2019

Log In or Create An Account

Get the latest Massachusetts jobs by following @recnetMA on Twitter!

Worcester RSS job feeds