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Utilization Review RN

Full / Part Time: Part-Time
Location: Greenfield, Massachusetts
Regular/Temporary: Regular

Baystate Health, a leading not-for-profit integrated health system, is transforming the delivery of health care to the communities it serves. Baystate Health (BH) is one of New England’s leading and largest integrated healthcare systems, serving more than 800,000 people throughout Western Massachusetts. With about 12,000 employees, a 1,200-member medical staff, and net patient service revenue of more than $2.3 billion, this dynamic and growing system includes an academic medical center, a children’s hospital and three community hospitals. It also includes a large multispecialty group, (Baystate Medical Practices), Baystate Home Health, Baystate Reference Laboratories, and Health New England, a 205,000-member health insurance company.

The mission of Baystate Health is “to improve the health of the people in our communities every day, with quality and compassion.” For over 130 years, Baystate has been a keystone of Western Massachusetts as it has evolved, grown, and emerged as one of the highest quality and most effective health care providers in the nation. Baystate Health was named a top 15 Health System in the country by Thompson Reuters; and is a PRC National Excellence in Healthcare Award Winner. Most recently US News and World Report ranked Baystate Medical Center and Massachusetts General Hospital as the only two hospitals in Massachusetts to achieve top quality ranking for five common procedures and conditions such as total joint replacement and congestive heart failure.

Baystate Health believes that the advancement of knowledge, through education and research, is essential to its mission of improving the health of the communities it serves. Baystate Medical Center has major programs in postgraduate medical education with residencies in Medicine, Surgery, Anesthesiology, Radiology, Pathology, OB/GYN, Pediatrics, Medicine-Pediatrics, Emergency Medicine, and Psychiatry; along with 22 fellowship programs.

Baystate Health is a forward-thinking organization. With impressive size, scope, and expertise, Baystate Health is the longtime market leader for health care services in western Massachusetts and is financially solid. However, as in most regions of the country, the healthcare landscape in western Massachusetts has shifted as a result of ever-increasing economic pressures and corresponding provider consolidation. Baystate Health is committed to its position as the key provider of tertiary level medical services to the people of Western Massachusetts. At the same time, Baystate Health has embraced a broader mission of promoting better health for the communities it serves and reducing health disparities. Baystate Health is committed to the provision of high value health care and is transforming how it delivers care and educates the next generation of physicians. One example of this is TechSpring, Baystate Health’s digital health care laboratory in downtown Springfield. Founded in June 2014, TechSpring works with entrepreneurs on ways that health care technology can fade into the background and take up less time.

In June 2015, Baystate Health established a new partnership with the UMass Medical School to develop a new regional clinical campus in Springfield, known as the University of Massachusetts Medical School – Baystate (UMMS-Baystate). UMMS-Baystate is now home to UMMS’ four-year Population-based Urban and Rural Community Health (PURCH) track, which welcomed its inaugural class of 22 medical students in Autumn 2017. Through this innovative program, the three institutions are partnering to strengthen the pipeline of new primary care physicians for the future in Western Massachusetts. These three institutions have also collaborated to create the Institute for Healthcare Delivery & Population Science, to generate and apply new knowledge to transform health care delivery and population health in support of Baystate Health’s strategic goals. The Institute conducts health services research projects in partnership with local, regional, and national stakeholders.

Baystate Franklin Medical Center (BFMC), located in Greenfield, MA, is an 89-bed community hospital that joined Baystate Health in 1986. The hospital boasts a state-of-the-art surgical center and a new endoscopy center that opened in August 2017. BFMC provides high-quality inpatient and outpatient services to communities in Franklin and Hampshire counties, as well as southern Vermont. Specialized programs include wound care and hyperbaric medicine, heart and vascular care, cancer care, family-centered obstetrical care, sports medicine, specialty medical and surgical services, inpatient behavioral medicine, and 24-hour emergency services.

The Utilization Review RN is a registered professional nurse responsible for the coordination of care, quality and financial outcomes for a designated population of patients.  The UR RN coordinates use of BH resources to assure that patients are provided optimal quality of care and service, researches and responds to all medical and behavioral health appeal inquiries and requests, in accordance with contractual, account, policy and accreditation requirements, conducts admission and concurrent reviews to obtain certification, facilitates and coordinates with internal and external customers in a proactive manner to bring review/appeal to satisfactory resolution, collaborates with payers through ongoing written and verbal communication to optimize the reimbursement potential for Baystate Franklin Medical Center, coordinates resolution of patient complaints regarding questionable and/or inappropriate charges, adheres to system and department compliance policies and any applicable laws and regulations and provides high quality customer service.

Performs Utilization Management Activities

  • Investigates issue in question and communicates resolution and/or information to  Patient Financial Services and/or other departments.  Coordinates communication efforts between Health Information Management, physicians and other members of the health care team to ensure optimal documentation necessary for accurate hospital coding and billing.  Refers appropriate cases to Manager and/or physician advisor for further review.  Uses Outlook, CIS, SMS, MIDAS+ as a tool for multidisciplinary communication.  Demonstrates the ability to use Outlook, CIS, SMS, MIDAS+ and Oracle information systems to retrieve and document clinical information accurately to track appeals cases and billing complaints.
  • Performs Utilization Management Activities. Conduct admission reviews for private insurers in order to obtain admission certification; conducts admission reviews for medical necessity and appropriate level of care. Collaborate with physician advisor when needed. Review medical record though manual and/or electronic systems using criteria established by the hospital and clinical input from physicians, care managers and interdisciplinary team. Act as a resource to the Care Management staff, physicians, and nurses with current knowledge of HINN, Medicare Important Message, ABN, and Condition Code 44. Deliver HINN, MIM, ABN to patients/families as required. Coordinate and complete continued stay reviews using established criteria and communicates with payers as appropriate, using established processes. Collaborate with physicians, care managers, socials work and makes recommendation regarding medical necessity for admission, continued stay, or alternative treatment facilities or agencies.
  • Provides post acute hospital care planning/discharge facilitation when needed.  Proactively works with the healthcare team to identify those patients who will need some level of care following their acute hospitalization.  Serves as an educator and mentor to others on the healthcare team on the process of post acute care planning.  Involves patients/families in the discharge planning process to facilitate a clear understanding by all parties.  Monitors each patient’s discharge plan of care for variance and makes appropriate recommendations and revises the plan as necessary.  Assures that interventions are in alignment with medical management initiatives.  Provides appropriate financial information to patients and/or families including scope of reimbursement sources.  Follows all state and federal guidelines in regards to patient rights in planning for their post acute needs.
  • Contributes to Day-To-Day Functioning of the Department. Demonstrates the ability to recognize and act on priorities promptly.  Willingly adjusts schedule to needs of department and co-workers.  Smoothly adjusts to temporary increases in workload.  Assists in maintaining Utilization Review/Appeals and Denials documents to reflect current workflow.  Responds to questions and inquiries from public and employees in a courteous and pleasant manner.  Identifies areas for improvement in departmental and hospital functions and communicates suggestions to manager.  Manages special projects as required by manager.
  • Assumes Responsibility for Own Professional Growth. Attends educational programs to maintain current knowledge in utilization management, denial management, with specific emphasis on own areas of responsibility.  Attends educational programs to maintain knowledge of current clinical management of patient problems on assigned clinical areas.  Attends regularly scheduled departmental and revenue operation meetings.  Establishes annual goals for professional growth and seeks opportunities that lead to the accomplishment of these goals
  • Participates in Quality Improvement of the Department. Participates in and supports Quality Improvement initiatives of the department.  Assess patient information for quality, infection control, risk management issues and makes appropriate referrals.

  • Bachelor’s Degree in Nursing Required
  • Minimum 3 years acute care clinical nursing experience-Case Management experience
  • Experience in utilization review process preferred
  • Ability to organize and prioritize workload in order to meet deadlines
  • Must possess excellent interpersonal skills, have full working knowledge and experience in health care delivery, management, regulations and health insurance models
  • Strong database management
  • Strong verbal and written communication skills
  • MA RN license

This is a 16 hour per week,  located in Greenfield, MA. Weekend and holiday rotation. Candidate must be able to attend orientation in Holyoke and Springfield, MA. 

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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