Medicare Utilization Management Nurse

3 days ago

Somerville, MA, United States Mass General Brigham Health Plan Full time

The Medicare UM Case Manager, RN performs utilization management activities primarily for Medicare Advantage, including review of authorizations for home care, high tech radiology, outpatient, inpatient, and post-acute services. The Medicare UMCM reviews the medical necessity of authorization requests using NCD, LCD, Medicare Benefit Policy Manual, medical policies, and InterQual criteria.

Education

  • Associate's Degree Nursing required; Bachelor's Degree Nursing preferred

Licenses and Credentials

  • Massachusetts Registered Nurse license required
  • Basic Life Support [BLS Certification] Certification preferred

Experience

  • At least 2-3 years of utilization management strongly preferred
  • Experience applying National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and Medicare Benefit Policy Manual preferred
  • InterQual experience preferred


Knowledge, Skills, and Abilities

  • Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
  • Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
  • Ability to establish strong rapport and relationships with patients and staff.
  • Proficient in Microsoft Office and industry-related software programs.
  • Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
  • Ability to maintain client and staff confidentiality.
  • Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
  • Knowledge of Healthcare and Managed Care preferred.

Working Conditions

  • This is a remote role that can be done from most US states


Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.

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