Job Description

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Time Type:

Full time

Department:

Senior Care Options (SCO)

All Locations:

10 Gove Street – Taylor BuildingWhat You'll Do

The Utilization Management (UM) Reviewer RN is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Utilization Management Review Nurse has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations.

This position requires universal skills and proficiencies which include demonstrating a comprehensive understanding of the Health Center’s mission and core values--compassion, diversity, innovation, respect. In addition, the SCO RN UM Reviewer initiative, critical thinking, problem solving, leadership qualities, and effectively engages with the clinical team.

What You'll Do

The Utilization Management (UM) Reviewer RN is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Utilization Management Review Nurse has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations.

This position requires universal skills and proficiencies which include demonstrating a comprehensive understanding of the Health Center’s mission and core values--compassion, diversity, innovation, respect. In addition, the SCO RN UM Reviewer initiative, critical thinking, problem solving, leadership qualities, and effectively engages with the clinical team.

The successful candidate will be able to perform the following responsibilities:

• Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements
• Meet or exceeds Timely authorizations
• Provides decision-making guidance to clinical teams on service planning as needed.
• Works closely with RN Case managers & Medical Director to facilitate escalated reviews in accordance with Standard Operating Procedures.
• Maintains consistent communication and collaboration with CCA UM team and SCO team relating to updates and program issues; ensures that Directors/Managers and peers are also informed of these matters.
• Functions as a team member, including active participation in staff meetings as appropriate to provide support, assistance, feedback.
• Promotes a sense of teamwork; maintains a positive and flexible/adaptable attitude. Open to new ideas and embraces change. Promotes a culture of acceptance, support and collegiality.

Other Duties:

Please note, this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

What You’ll Bring

• Bachelor’s degree in Science in Nursing degree preferred
• 3-5 years of progressive experience working in a health plan preferred
• Minimum of 5 years’ experience in healthcare or multi-site clinics required.
• Strong interpersonal and communication skills, with the ability to build rapport across diverse teams.
• Solid knowledge of prior authorizations and clinical expertise to interpret clinical criteria to determine medical necessity of services.
• Exceptional problem-solving and conflict-resolution abilities.
• Ability to handle sensitive and confidential matters with professionalism and discretion.
• Proficiency in Microsoft Office Suite.
• The ability to work in a fast-paced environment.

Work Environment & Physical Requirements

• Regularly required to sit, stand, walk, and use hands to operate a computer and other office equipment.
• Must be able to remain in a stationary position for extended periods while performing administrative and computer-based tasks.
• Occasionally required to lift or move items weighing up to 20 pounds (such as files, office supplies, or small equipment).
• Must have adequate visual acuity, hearing, and manual dexterity to perform essential job functions.
• Expected to follow all NeighborHealth and OSHA safety policies and procedures, including maintaining a safe and ergonomic work environment.

Salary: Starting at $44/hr up to $64/hr based on experience

EEO & Accommodation Statement:

NeighborHealth is an equal employment/affirmative action employer. We ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic. If you need accommodation for any part of the application process because of a medical condition or disability, please send an e-mail to HRrecruit@NeighborHealth.com or call 617-568-4480 to let us know the nature of your request

Federal Trade Commission Statement:
According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website. We do not ask or require downloads of any applications, or “apps.” Job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.

E-Verify Program Participation Statement:

NeighborHealth participates in the Electronic Employment Verification Program, E-Verify. As an E-Verify employer, all prospective employees must complete a background check before beginning employment.