UM Nurse
2 weeks ago
Overview
About us:
Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.
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 pre-service, concurrent, and retrospective reviews for Acute Hospital and post-acute facility level of utilizing established Care Coordination polices and protocols, Fallon Health benefit criteria, applicable regulatory review criteria and nationally accepted criteria for medical necessity determinations.
Responsibilities
* Obtain clinical, functional, and psychosocial information from the medical records on site, through remote electronic access, telephonically or by fax in a collaborative effort with other health care professionals, member and/or family
* Refers cases to medical review according to policy and procedure
* Documents clinical, functional, psychosocial information in the Core System as well as communications regarding the members' care
* Keeps records and submits reports as assigned by the Manager
* Refers high-risk cases to the Case Management Department, Government Services Clinical Programs, Fallon Clinic Care Coordination
* Department and/or other community services according to department protocol
* Collaborates with attending physicians and health care professionals regarding appropriate utilization of medical services
* Completes level of care reviews strictly adhering to regulatory turnaround time guidelines such as, but not limited to, CMS NCQA, and the DOI
* Identifies utilization issues unique to their team assignment and identifies strategies to address/resolve these issues
* Issues regulatory and other letters according to the department policies and procedures.
* Electronic copies of all denial letters and related documents are kept in the Fallon Health core application and/or the organization's security accessed drive(s)
* Acts as a 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
* Works with Fallon Health providers/support staff and/or members to facilitate cost-effective, quality care
* Requests and obtains relevant clinical information from medical care providers as needed for the clinical review process
* Conducts clinical reviews of retrospective and concurrent Acute Inpatient Hospital and proposed post-Acute level of care requests against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status
* Conducts concurrent Inpatient Hospital and Post-Acute level of care reviews, authorizing continuation of services meeting criteria
* Refers all cases that do not meet medical necessity, benefit eligibility, and network contract status criteria to a physician reviewer for consideration, ensuring the timely review of the referred case
* Identifies and refers readmission reviews to a physician reviewer for consideration, ensuring the timely review of the referred case
* Incrementally monitors the effectiveness of established plans of care with defined, measurable goals and objectives and cost-benefit documentation as applicable and modifies the care plan when applicable.
* Streamlines the focus of the member's healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care.
* Analyzes and applies CMS always INPT and SDS CPT codes during UM clinical reviews
* Collaborates with Fallon Health departments to ensure services/items needed to facilitate discharge from a post-acute or hospital setting do not delay discharge
* Collaborate with external Facility Case Managers and Social Workers on alternate level of care options when services requested do not meet medical necessity, benefit eligibility, and network contract status criteria
* Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the member attains pre-determined outcomes
* Reviews physician reviewers' determinations for appropriateness and completeness
* Communicates determinations to providers and members telephonically and in writing, adhering to corporate/department Communicates determinations to providers and members telephonically and in writing, adhering to corporate/department policy and regulatory guidelines
* Will check voicemail at regular intervals throughout the day and returns calls/messages within the same day of receipt
* Strictly observes the Fallon Health policies regarding confidentiality of member information, documentation standards, meeting any education requirements, and performs other responsibilities as assigned by department management team
* Participates in weekly medical rounds with the leadership team, Medical Directors, and various Fallon Health departments to discuss patient issues and/or concerns. Organizes and presents complex medical cases in a clear and concise oral and written manner
* Ensures ad hoc contracts are in place for non-contracted services working in conjunction with FH Network Development team
Qualifications
Education
Graduate from an accredited school of nursing, or Bachelors (or advanced) degree in nursing required.
License/Certifications
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' e
-
Lead, Inpatient UM Nurse Capped
1 week ago
Los Angeles, CA, United States MedPOINT Management Full timeSummaryJob DescriptionProvides leadership, support, training, and direction to the Inpatient UM teammates. The incumbent will use clinical judgment to provide utilization management review for inpatient during high volume situations. Provide high quality, cost-effective care to enable patients to achieve maximum medical improvement, while receiving care...
-
San Antonio, TX, United States UnitedHealth Group Inc Full timeRegistered Nurse RN Concurrent UM Review WellMed Compact LicenseOpportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and...
-
Bel Air, MD, United States University of Maryland Medical Center Baltimore Washington Full timeJob Description UM Upper Chesapeake Health (UM UCH), a member of the University of Maryland Medical System (UMMS), has a Full-time employed position available for a Nurse Practitioner Program Coordinator to join their reputable, well-established Comprehensive CARE Center (a transitional care clinic) located on the UM Upper Chesapeake Medical Center campus...
-
Palliative Care Nurse Practitioner
2 weeks ago
Easton, MD, United States University of Maryland Medical System Full timeCompany DescriptionUniversity of Maryland Medical System (UMMS) is a physician-led, internationally recognized healthcare system offering uniquely rewarding careers in major Maryland marketplaces. Create your future in a healthcare setting that is right for you and your practice. Become part of something greater by applying your experience, input, and...
-
Certified Registered Nurse Anesthetist
2 weeks ago
Towson, MD, United States University of Maryland Medical System Full timeCompany DescriptionWhen you come to the University of Maryland St. Joseph Medical Center, you’re coming to more than simply a beautiful 37-acre, 218-bed suburban Baltimore, Maryland campus. You’re embarking on a professional journey that encourages opportunities, values a team atmosphere, and makes convenience and flexibility a priority. Joining our team...
-
Registered Nurse
4 days ago
downey, CA, United States PIH Health Full timeThe Utilization Management (UM) RN performs utilization review activities, including, but not limited to, precertification, ensures appropriate level of care and status (Inpatient, Outpatient, and Observation) throughout admission and performs initial reviews, concurrent reviews, and retrospective reviews according to guidelines. Determines the medical...
-
Bel Air, MD, United States University of Maryland Medical System Full timeCompany DescriptionUniversity of Maryland Upper Chesapeake Health (UM UCH) offers the residents of northeastern Maryland an unparalleled combination of clinical expertise, leading-edge technology, and an exceptional patient experience.A community-based, integrated, non-profit health system, our vision is to become the preferred, integrated health system...
-
Certified Registered Nurse Anesthetist
2 weeks ago
Baltimore, MD, United States University of Maryland Medical Center Baltimore Washington Full timeJob Description This position provides anesthetic care in collaboration with anesthesiologists, surgeons, physicians, and medical professionals in every practice setting throughout UM Rehab & Ortho Institute. The CRNA will administer anesthesia and anesthesia-related care in four general categories: * Pre-anesthetic preparation and evaluation * Anesthesia...
-
Registered Nurse II
2 weeks ago
Largo, MD, United States University of Maryland Medical System Full timeCompany DescriptionAt UM Capital Region Health, we’re about to changeUP everything with the opening of our new hospital in Spring 2021!Located in Largo in the heart of Prince George’s County, our new state-of-the-art regional medical center (UM Capital Region Medical Center) will provide improved access to primary and ambulatory care services, and serve...
-
downey, CA, United States PIH Health Full timeThe Utilization Management (UM) LVN performs utilization review activities, including, but not limited to, precertification, ensures appropriate level of care and status (Inpatient, Outpatient, and Observation) throughout admission and performs concurrent reviews/retrospective reviews according to guidelines. In addition, the UM LVN delegates to UM RN...
-
Registered Nurse
2 weeks ago
Glen Burnie, MD, United States University of Maryland Medical Center Baltimore Washington Full timeJob Description Shift Schedule: Full-time/Night/0.9 8:00PM - 8:30AM, rotating weekends and holidays Location: Baltimore Washington Medical Center The Power of Caring Within all of us there is untold power. An unstoppable strength. A desire to do more. Join our talented team of Registered Nurses and experience the highest level of appreciation at UM...
-
Registered Nurse
2 weeks ago
Glen Burnie, MD, United States University of Maryland Medical Center Baltimore Washington Full timeJob Description Shift Schedule: PRN/Rotating/0.0 8:00AM - 8:30PM or 8:00PM - 8:30AM, rotating weekends and holidays Location: Baltimore Washington Medical Center The Power of Caring Within all of us there is untold power. An unstoppable strength. A desire to do more. Join our talented team of Registered Nurses and experience the highest level of...
-
Pulmonary Nurse Practitioner
2 weeks ago
Towson, MD, United States University of Maryland Medical Center Baltimore Washington Full timeJob Description UM St. Joseph Medical Group (UMSJMG), a member of the University of Maryland Medical System (UMMS), has a full-time employed position available for a Pulmonary and Sleep Medicine Nurse Practitioner or Physician Assistant to join their practice located in Towson, MD. Nurse Practitioner Job Specifics: * Position dedicated to the management...
-
Registered Nurse
2 weeks ago
Glen Burnie, MD, United States University of Maryland Medical Center Baltimore Washington Full timeJob Description Shift Schedule: Part-time/Day/0.6 8:00AM - 8:30PM, rotating weekend and holiday. Location: Baltimore Washington Medical Center The Power of Caring Within all of us there is untold power. An unstoppable strength. A desire to do more. Join our talented team of Registered Nurses and experience the highest level of appreciation at UM...
-
Licensed Practical Nurse, Nights
2 weeks ago
Towson, MD, United States University of Maryland Medical Center Baltimore Washington Full timeJob Description * Participates as a member of the patient care team by providing direct patient care under the supervision of the RN. * Maintains accountability for meeting basic physical, psychosocial and environmental needs of the patient. * Performs any and all duties involving direct patient care as assigned by the RN within guidelines provided by the...
-
Registered Nurse
2 weeks ago
Baltimore, MD, United States University of Maryland Medical Center Baltimore Washington Full timeJob Description What's In it for you?! * Low Nurse- to- patient ratios (1:6) * UMROI is a true rehabilitation facility where we operate in the capacity more parallel to a Med Surg unit and not a skilled nursing facility. * Patients receive 3 hours of therapy a day resulting in increased physical recovery for patients. Providers, therapists, and nurses work...
-
Licensed Practical Nurse, Nights
2 weeks ago
Towson, MD, United States University of Maryland Medical System Full timeCompany DescriptionWhen you come to the University of Maryland St. Joseph Medical Center, you’re coming to more than simply a beautiful 37-acre, 218-bed suburban Baltimore, Maryland campus. You’re embarking on a professional journey that encourages opportunities, values a team atmosphere, and makes convenience and flexibility a priority. Joining our team...
-
Registered Nurse
2 weeks ago
Glen Burnie, MD, United States University of Maryland Medical System Full timeCompany DescriptionExperience the highest level of appreciation at UM Baltimore Washington Medical Center — named Top Workplace in the Baltimore area by The Baltimore Sun two years in a row (2019 & 2020); Top Workplace in the USA for 2021! As part of the acclaimed University of Maryland Medical System, our facility is one of three ANCC Pathway to...
-
Clinical Nurse 2
2 weeks ago
Bel Air, MD, United States University of Maryland Medical System Full timeCompany DescriptionUniversity of Maryland Upper Chesapeake Health (UM UCH) offers the residents of northeastern Maryland an unparalleled combination of clinical expertise, leading-edge technology, and an exceptional patient experience.A community-based, integrated, non-profit health system, our vision is to become the preferred, integrated health system...
-
Wound Ostomy Coordinator, Registered Nurse
2 weeks ago
Largo, MD, United States University of Maryland Medical System Full timeCompany DescriptionLocated in Largo in the heart of Prince George’s County, our new state-of-the-art regional medical center (UM Capital Region Medical Center) will provide improved access to primary and ambulatory care services, and serve as a tertiary care center for critically ill patients. In addition, our new space will allow us to expand our...
