Utilization Management Nurse

Mass General Brigham Assembly Square, MA 02145, US

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Given equity, this position will pay somewhere between $90,000 to $107,000 annually.

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.

We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.

The UMCM will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review, as well as complete determinations following physician review. The ideal candidate will have prior authorization experience in a managed care setting with Medicaid/ACO health plan knowledge.

Principal Duties and Responsibilities:
• Expertise in clinical review for prospective, concurrent, retrospective utilization management reviews utilizing Interqual ®, company policies and procedures, and other resources as determined by review, including physician reviews as needed for all lines of business as per departmental needs
• Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within Mass General Brigham Health Plan as needed.
• Manage incoming requests for procedures and services, including patient medical records and related clinical information.
• Strong working knowledge of commercial, self-insured, fully insured and limited network plans.
• Adherence to program, departmental, and organizational performance metrics, including productivity.
• Excellent verbal and written communication skills.
• Excellent problem-solving and customer service skills.
• Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire.
• Must be self-directed and highly motivated with an ability to multi-task.
• Develop and maintain effective working relationships with internal and external customers
• Hold self and others accountable to meet commitments.
• Sound decision-making and time management skills.
• Proactive in areas of professional development, personally and for the department.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
• Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual ®, Outlook, SharePoint, PC based operating system, and web-based phone system.

Qualifications

Education

Associate's Degree Nursing required or Bachelor's Degree Nursing preferred

Licenses and Credentials

Massachusetts Registered Nurse (RN) license required

Experience

At least 2-3 years of utilization review experience is highly preferred
Experience using Interqual or Milliman is highly preferred
At least 1-2 years of experience in a payer setting is highly preferred
At least 1-2 years of experience in an acute care setting is highly preferred

Knowledge, Skills, and Abilities

Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value
Strong aptitude for technology-based solutions.
Embrace opportunities to take the complexity out of how we work and what we deliver.
Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation
Current in healthcare trends.
Ability to inject energy, when and where it’s needed.
Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
Be accountable for delivering high-quality work. Act with a clear sense of ownership.
Bring fresh ideas forward by actively listening to and working with employees and the people we serve.
Communicate respectfully and professionally with colleagues
Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.

Additional Job Details (if applicable)

Working Conditions

Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire.
This is a remote role with occasional onsite team meetings in Somerville, MA.

Given equity, this position will pay somewhere between $90,000 to $107,000 annually.

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$58,656.00 - $142,448.80/Annual

Grade

98TEMP

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

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Registered Nurse, Med Surg unit, Marlborough, Nights, 36-hours

UMass Memorial Health Marlborough, MA

Are you a current UMass Memorial Health caregiver? Apply now through Workday. Exemption Status: Non-Exempt Hiring Range: $38.65 - $78.34 Please note that the final offer may vary within this range based on a candidate’s experience, skills, qualifications, and internal equity considerations . Schedule Details: Sunday through Saturday Scheduled Hours: 1845-0715 Shift: 3 - Night Shift, 12.5 Hours (United States of America) Hours: 36 Cost Center: 10021 - 0226 Nursing 2 Union: MNA-Marlborough (Massachusetts Nurses Association) This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process. Everyone Is a Caregiver At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day. Responsible for the planning, delivery and management of direct patient care utilizing the nursing process and adhering to the standards of nursing practice. I. Major Responsibilities: 1. Utilizes the Nursing Process for the delivery and management of patient’s care from Admission to Discharge, appropriate to the developmental age of the patient population. 2. Performs patient assessment/reassessment according to standard procedure. 3. Develops and coordinates individual plan of care including discharge planning. 4. Directs, supervises, coordinates and evaluate nursing care within assigned clinical setting. 5. Delegates appropriately to others in accordance with job description and competency level. II. Position Qualifications: License/Certification/Education: Required: 1. Current Massachusetts Nursing licensure and registration. 2. BLS is a requirement for every RN unless advance cardiac life support (ACLS) certification is current, in addition to any unit specific certifications and competencies. Preferred : 1. Bachelor of Science degree in Nursing highly preferred. Experience/Skills: Required: 1. Thorough knowledge of the discipline of Nursing. Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements. Department-specific competencies and their measurements will be developed and maintained in the individual departments. The competencies will be maintained and attached to the departmental job description. Responsible managers will review competencies with position incumbents. III. Physical Demands and Environmental Conditions: Work is considered medium. Position requires work indoors in a patient care environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. We’re striving to make respect a part of everything we do at UMass Memorial Health – for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day. As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law. If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at talentacquisition@umassmemorial.org. We will make every effort to respond to your request for disability assistance as soon as possible.

Nursing Supervisor - Field Operations

Option Care Health Marlborough, MA

$97,554.56 - $162,583.73 / year

Extraordinary Careers. Endless Possibilities. With the nation’s largest home infusion provider, there is no limit to the growth of your career. Option Care Health, Inc. is the largest independent home and alternate site infusion services provider in the United States. With over 8,000 team members including 5,000 clinicians, we work compassionately to elevate standards of care for patients with acute and chronic conditions in all 50 states. Through our clinical leadership, expertise and national scale, Option Care Health is re-imagining the infusion care experience for patients, customers and team members. Join a company that is taking action to develop an inclusive, respectful, engaging and rewarding culture for all team members. At Option Care Health your voice is heard, your work is valued, and you’re empowered to grow. Cultivating a team with a variety of talents, backgrounds and perspectives makes us stronger, innovative, and more impactful. Our organization requires extraordinary people to provide extraordinary care, so we are investing in a culture that attracts, hires and retains the best and brightest talent in healthcare. Job Description Summary: A Nursing Supervisor is a licensed professional who provides direct and indirect patient care services under a physician’s plan of care and in accordance with the policies and procedures of Option Care Health, the state’s professional standards, and regulatory entities. The Nursing Supervisor is responsible for providing and overseeing complete patient assessment, care planning, patient, and caregiver education, evaluating progress toward goals and recommendations for changes in the plan of care. The Nursing Supervisors additional competencies allow for independence in the practice of the specialty and positions the Nursing Supervisor to train and oversee pertinent competencies. Clinical competency is maintained by providing direct patient care 20-40% of the time. In a Medicare Certified Home Health agency, this position may also serve as the alternate administrator and or alternate director of nursing. **The Nurse Supervisor/Nurse Manager/Regional Nurse Manager, Director, Nursing, or a designated registered nurse (RN) acting on their behalf, must be physically present on the premises or immediately accessible via telecommunication at all times during operating hours when patients are receiving infusion services.** Job Description: Job Responsibilities (listed in order of importance and/or time spent) Competent in the clinical management of home infusion patients including Patient management skills, the Nursing Process, the rules of Federal, state, and local regulatory entities that oversee and control the provision of care in a Home Health Agency. Knowledgeable of documentation and billing requirements for home health/ infusion care goods and services. Determines suitability of patients for home care. Supervises, monitors, and evaluates the quality and effectiveness of patient care, including, when appropriate, in home evaluations of field staff. Reviews and monitors appropriateness of Nursing Care Plans and directs the staff to modify the plan as needed. Acts as Administrator and/or Director of Nursing of the Home Health Agency for Medicare certified home health agencies in the absence of a director or Manager of Nursing. Manages daily activities with regards to effective operations and communications and ensures the office remains in compliance with all regulating and accreditation entities. Complies with reporting requirements, ensures policy and procedure, compliance and monitors and evaluates medical supply usage. Participates in the process for assessing, managing, and reporting nursing operational and financial data to the Regional Nurse Manager, Area Director of Nursing, and/or Director of Operations. Supports the development and implementation of the Plan of Care for each patient. Develops, implements, evaluates, and participates in office specific continuing education and orientation programs. Assists the Director of Operations, Area Director of Nursing and/or the Nurse Manager in the recruitment, development, and monitoring of new staff. Coordinates and participates in on-call responsibilities. Maintains confidentiality of patient and proprietary information. Participates as a member of or directs the professional advisory committee, infection prevention and process improvement teams, including conducting chart audits. Identifies opportunities for improvement and communicates to the Nurse Manager, Area Director of Nursing and/or Director of Operations. Speaks knowledgeably of the scope of services that are available through Option Care and provides support to sales professionals on an ongoing basis. Supervisory Responsibilities Does this position have supervisory responsibilities? (i.e. hiring, recommending/approving promotions and pay increases, scheduling, performance reviews, discipline, etc.) No Yes X Basic Education and/or Experience Requirements Registered Nurse with a license in the current state of practice with 1 year of nursing supervisory/charge experience, or at least 3 years of relevant nursing experience with demonstrated progression. Required certification in CPR. Member of a state or national professional organization. Basic Qualifications & Interests (BQIs) Access to a reliable means of transportation, which will enable the incumbents to make home visits to treat/attend to their patients. If such means of transportation would include a personal vehicle, a valid driver’s license and a proof of insurance would be required. Experience applying knowledge of local, State, Federal, accrediting body, and OSHA rules and regulations. Experience providing customer service to internal and external customers, including meeting quality standards for services, and evaluation of customer satisfaction. Experience in the indirect management of team members, including assisting in the development, training, and assignment of work/projects to other members of a team. Experience using time management skills such as prioritizing/organizing and tracking details and meeting deadlines of multiple projects with varying completion dates. Basic level skill in Microsoft Word (for example: opening a document, cutting, pasting, and aligning text, selecting font type and size, changing margins and column width, sorting, inserting bullets, pictures and dates, using find and replace, undo, spell check, track changes, review pane and/or print functions). Basic level skill in Microsoft Excel (for example: opening a workbook, inserting a row, selecting font style and size, formatting cells as currency, using copy, paste and save functions, aligning text, selecting cells, renaming a worksheet, inserting a column, selecting a chart style, inserting a worksheet, setting margins, selecting page orientation, using spell check and/or printing worksheets). Basic skill level in Microsoft PowerPoint (for example: inserting, rearranging, hiding, and deleting slides, navigating between slides, increasing list level, adding, centering and editing text, changing views, inserting a table or a note, moving objects, printing outline view and/or running a slide show). Experience developing ways of accomplishing goals with little or no supervision, depending on oneself to complete objectives and determining when escalation of issues is necessary. Travel Requirements : (if required) Willing to travel at least 50% of the time for business purposes (within state and out of state). Preferred Qualifications & Interests (PQIs) BSN CRNI or other professional certification. At least 1 year of supervisory experience in a hospital or home health care setting is preferred. At least 1 year of experience in the indirect management of team members, including assisting in the development, training, and assignment of work/projects to other team members is preferred. This job description is to be used as a guide for accomplishing Company and department objectives, and only covers the primary functions and responsibilities of the position. It is in no way to be construed as an all-encompassing list of duties. Due to state pay transparency laws, the full range for the position is below: Salary to be determined by the applicant's education, experience, knowledge, skills, and abilities, as well as internal equity and alignment with market data. Pay Range is $97,554.56-$162,583.73 Benefits: -Medical, Dental, & Vision Insurance -Paid Time off -Bonding Time Off -401K Retirement Savings Plan with Company Match -HSA Company Match -Flexible Spending Accounts -Tuition Reimbursement -myFlexPay -Family Support -Mental Health Services -Company Paid Life Insurance -Award/Recognition Programs Option Care Health subscribes to a policy of equal employment opportunity, making employment available without regard to race, color, religion, national origin, citizenship status according to the Immigration Reform and Control Act of 1986, sex, sexual orientation, gender identity, age, disability, veteran status, or genetic information.