Utilization Management Nurse BWH

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.

About the Role

The Insurance Support Nurse participates in the timely management of denials received in the Care Coordination Department. Through sound knowledge of utilization management, the nurse assesses a patient's level of care after reviewing the medical record. The nurse is part of the care coordination staff and works closely with care coordination, medical, and nursing teams to appeal denied claims, expedite appeal processes, and case closure. The nurse also collaborates with admitting and finance staff to process denied claims. For newly licensed nurses, a Bachelor of Science Degree in Nursing is required. This position does not require direct patient care.

Responsibilities

• Utilization Management
  • Collaborates with appropriate individuals, departments, and payers to ensure appropriateness of admission, continued days of stay, and reimbursement.
  • Applies industry-accepted utilization and medical management criteria to cases retrospectively to determine appropriateness of admission, days of stay, level of care, and over/under utilization.
  • Demonstrates working knowledge of industry criteria sets like Milliman and InterQual.
  • Shows in-depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs, commercial insurances, and plan types such as PPO, HMO, or indemnity.
  • Serves as a resource to staff and physicians for questions about the denial of care for Medicare, Medicaid, or other insurances.
  • Assists with the preparation of denial notices given to patients.
  • Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Denial Management
  • Coordinates the filing of appeals for clinical denials and works with other departments to ensure payment for care provided.
  • Reviews denial letters and sends letters to other departments if appropriate.
  • Communicates with attending physicians and care coordination nurses around notification of denial of care to understand patient care needs.
  • Works with physician advisors to write appeal letters for denied care and sends letters to insurance companies.
  • Documents denials in the BWH/MGB’s Denial Database.
  • Follows up with insurance companies on claims status for clinical denials.
• Team Work
  • Assists with various functions and responsibilities of the care coordination department to ensure compliance with all state and federal mandates.
  • Participates in the ongoing evaluation of practice patterns and systems to support efforts to improve quality, cost, and satisfaction outcomes.
  • Serves as an expert on observation status and reviews observation patients as assigned.
  • Assists in the completion of utilization reviews to insurers and intermediaries.
  • Anticipates and troubleshoots claim and reimbursement issues.
  • Assists in the review of Medicare reports as assigned.
  • Participates in BWH and MGB’s Finance projects.
  • Active member of the ATO/Denial Committee and UR Committee.
  • Performs other duties as assigned.

Requirements

• Bachelor's Degree in Nursing required (experience may be accepted in lieu of a degree).
• Massachusetts Registered Nurse license.
• Previous experience in a hospital or healthcare setting required.
• Hospital utilization review and medical criteria sets experience required.
• Five years of medical or surgical staff nurse experience required.
• Experience with leveling tool criteria (such as InterQual or Milliman) required.

Skills

• Strong clinical assessment skills.
• Excellent interpersonal skills, including the ability to work collaboratively within a team and with internal and external customers.
• Strong organizational skills and ability to set priorities.
• Ability to compile data from concurrent and retrospective medical reviews to determine clinical appropriateness, level of care, and discharge plans.
• Excellent written and verbal communication skills.
• Proficiency in computer skills.
• Knowledge and skills to differentiate levels of care.

Additional Details

This is a per diem, rotating day shift position. Work location is 45 Francis Street, with remote work options available.

Pay

Hourly pay range: $41.71 - $105.65.