UM Outpatient Clinical Review Nurse, Health New England

Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.

Minimum - Midpoint - Maximum

$87,859.00 - $100,984.00 - $119,412.00

 

 

UM Outpatient Clinical Review Nurse- Baystate Health, Health New England

This is a full-time remote opportunity. Current States Eligible MA and CT

The UM Outpatient Clinical Review Nurse contributes to the overall success of the Utilization Management department by performing clinical reviews for outpatient, including determining the member’s overall health, reviewing the type of care being delivered, and evaluating medical necessity, in compliance with governing regulations, internal policies, and procedures.  

Responsibilities  

• Performs pre-service, concurrent, and retrospective reviews of members for appropriate care and setting to determine overall health and appropriate level of care, using applicable coverage documents and clinical guidelines 
• Collects, documents, and maintains review findings and actions taken on member medical records in health management systems, according to utilization management policies and guidelines 
• Works with healthcare providers to approve medical determinations or provide recommendations based on requested service and review findings 
• Collaborates with Medical Directors, when determination to deny a request is indicated  
• Assists with providing education to providers on utilization processes to ensure high quality, appropriate care to members 
• Collaborates with care management on referral of members, as appropriate 
• Performs clinical reviews for member and provider appeals related to outpatient services 
• Participates in the weekend call program, as well as flexible work hours, as needed within the department 
• Provides input to the Medical Policy Committee regarding the development/updating of medical policies 

Education/Experience:

• Current MA RN License required 
• Bachelor's degree preferred and 3-5 years nursing experience
• Knowledge of utilization management, Medicare and Medicaid strongly preferred  
• Highly developed critical thinking skills- prior nursing experience ICU or ER  
• Computer literacy and ability to navigate through computer systems 
• Excellent written and verbal communication skills, including delivering presentations 
• Excellent time management skills with the ability to manage multiple priorities 
• Ability to manage an assigned caseload independently 
• Strong teamwork skills 

THE ADVANTAGES OF WORKING WITH BAYSTATE!

• Excellent C