UM Nurse Manager

Summary: Create, build and maintain a comprehensive UM program utilizing vendors, tools and internal and external resources.  Drive positive outcomes by supporting all stakeholders including patient, family, caregivers, providers, SHIP clients, and our UM vendors. This role will involve working with clinical and business entities requiring collaboration with a diverse group of stakeholders and work through vendors to enhance the program, workflows, tools, reports and analytics. The role will involve collaborating with healthcare providers and vendors to promote quality outcomes and effective use of resources.

Qualifications:

  • Current unrestricted RN license, BSN preferred, 7+ years of experience;
  • 5 or more years of UM Experience in Managed Care as UM nurse, case manager, concurrent review nurse or utilization review nurse;
  • Healthcare Payer experience;
  • Experience with EMRs, UM/CM software tools (Milliman/InterQual), pre-certification, concurrent review, prior authorization, care coordination, & discharge planning; 
  • Basic knowledge of health care contracts, benefit eligibility requirements, hospital structure and payment systems preferred;
  • Ability to work autonomously yet be a part of the medical management team;
  • Certified Case Manager (CCM) a plus;
  • Thorough knowledge of utilization and case management programs and application of related clinical criteria and protocols;
  • Ability to multitask and work across departments within the organization and with external vendors to ensure quality of services are cost effective. 
  • Computer proficiency skills in MS office suite is desired.
  • Strong managerial background preferred.  

General Job Duties and Responsibilities: 

  • Monitor, track, manage and interface with UM vendors and primary networks; 
  • Interface with secondary networks and OON facilities to apply medical necessity standards; 
  • Review plans with Colleges and Universities and agreements with vendors to recommend changes that will improve quality while reducing the cost of care;
  • Support and recommend changes to our accreditation applications;
  • Primary contact for medical and administrative staff for utilization management.
  • Monitor utilization: trends, patterns, and impact;
  • Trains, hires, evaluates and monitors performance of clinical quality nurse(s);
  • Ensure compliance with federal/state regulations, other agencies, and internal policies and procedures and facilitates training for medical staff on UM issues.
  • Managing our vendors that provide UM and CM services.
  • Ensure medically appropriate, high quality, cost effective care for inpatient admissions, outpatient services, surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting 
  • Interprets appropriateness of care and accurate claims payment.
  • Monitors pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews for medical necessity
  • Works with clinical reviewers and CMO to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
  • Facilitates collaboration with providers for early identification and proactive planning for discharge planning.
  • Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
  • Manage UM, UR and concurrent review processes and workflows  
  • Validate medical appropriateness of inpatient and outpatient services 
  • Translate concepts into practice, i.e. deploy solutions  
  • Manage, coach, provide feedback and guide staff and vendors  
  • Continually evaluate and recommend improvements to UM and Case Management   
  • Work with Medical Director and prepare and present cases for his/her review 
  • Ensure timely and accurate documentation in database of UM decision
  • Day-to-day direction to UM Team to meet department goals and objectives.
  • Create and complete performance metrics, reports and evaluations for the department and team
  • Participates in the grievance process.
  • Monitors quality of care issues and trends.
  • Produces summary of UM activities quarterly
  • Manages medical claims review and appeals to ensure timely accurate response
  • Collaborates with BH providers and other internal/external organizations
  • Updates policies and procedures annually or as needed as determined by QAUMC.
  • Participates in UM vendor audits and prepares report for department
  • Identifies opportunities for improvement and develops action plans
  • Develops standardized training material for new and existing staff
  • Monitors retrospective reviews, in the aggregate and on an individual basis, and analyzes and reports findings to the CMO
  • Promotes continuous quality improvement and implements recommended changes.
  • Participates in cost containment efforts of CHP
  • Works with other departments to develop & implement work process improvements
  • Other duties as assigned

Please send your resume and completed application to CHP Human Resources at:

Mail: Consolidated Health Plans, Human Resources, 2077 Roosevelt Avenue, Springfield, MA 01104-3503

Fax: (413) 452-5329 Attn. Human Resources

Email: human_resources@consolidatedhealthplan.com

Phone: (413) 733-4540 ext. 120

 

Employment Application

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For more information contact us at human_resources@consolidatedhealthplan.com or call us at (413) 733-4540 ext. 120