Fallon Health RN - Utilization Management - Health Insurance in Worcester, Massachusetts
About 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.
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 review
to 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.
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.
Education : 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.
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.
Job ID 5211
# Positions 1