Job ID R5908 Full / Part Time:Part time
Full / Part Time:Part time
Responsible for the coordination and direction of all utilization/case management activities to support and implement the goals of the utilization management program and plan. Maintains oversight responsibility for the review of medical necessity and appropriateness of care against screening criteria and for infection control, quality and risk assessment. Coordinates the discharge planning function in conjunction with the discharge planner/social worker, assist with investigation and problem solving as needed. Assists the medical director with all utilization activities as requested and directed. Responsible for coordination and presentation of utilization management program. Directs performance improvement activities within the department.
1) Works with denial management to provide applicable information to the team to assist in the appeals process.
2) Communicates appropriately and clearly to department director, physicians, staff, CNO, administrative team and billing department.
3) Reviews utilization management activities for occurrences and trends that affect the quality, cost effectiveness and delivery of services. Assures that the outcome of review is appropriately maintained.
4) Consults other departments, as appropriate, to collaborate in patient care and performance improvement activities. Collaborates with other departments to identify operational problems and develop solutions/resolution.
5) Collects and prepares the documentation for the resolution of appeals and grievances.
6) Utilizes Interqual criteria including Cerme.
7) Assists Patient Accounts in solving issues regarding patient billing.
8) Works at maintaining good rapport and a cooperative working relationship with peers.
9) Adheres to dress code, appearance is neat and clean.
10) Reports to work on time and as scheduled, completes work within designated time.
11) Wears identification while on duty, uses computerized punch time system correctly.
12) Represents the organization in a positive and professional manner.
13) Complies with all organizational policies regarding ethical business practices.
14) Communicates the mission, ethics and goals of the hospital.
15) Completes annual education requirements
16) Maintains regulatory requirements
17) Maintains patient confidentiality at all times regarding HIPAA regulations.
18) Attends/participates in the Utilization Management Committee meetings.
19) Resolves personnel concerns at the departmental level, utilizing the grievance process as required.
20) Ensures compliance with policies and procedures regarding operations, fire, safety and infection control. Actively participates in performance improvement activities.Required Work Experience:
1) 1 or more years utilization management experience in the managed care environment preferred
2) 1 or more years acute hospital, home health, hospice, inpatient mental facility experience requiredPreferred Work Experience:
1) None ListedSkills and Competencies:
1) Ability to effectively communicate in English, both verbally and in writing
Education:Bachelor of Science (Required)
Certifications:Registered Nurse - State of Massachusetts
Competencies:Collaboration, Courage, Ownership, Service focus, Values Differences
Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.
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