• Job Description

  Req#: RQ4027140
  Site: The Brigham and Women's Hospital, 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.

  
  

  Staff Nurse - 40hr Variable Day - BWH Utilization Managment

  
  

  Job Summary

  The Insurance Support Nurse participates in the timely management of denials that are received in the Care Coordination Department. Through sound knowledge of utilization management, the nurse is able to assess a patient's level of care after review of the medical record. The nurse is a part of the care coordination staff and works closely with care coordination, medical and nursing staff to appeal denied claims and expedite appeal processes and case closure. The nurse works closely with admitting and finance staff, to process denied claims.
  
  For newly licensed nurses a Bachelor of Science Degree in Nursing is required.
  
  Does this position require Patient Care? No
  
  Essential Functions
  
  - Utilization Management
  
  Collaborates with appropriate individuals, departments and payers to ensure appropriateness of admission, continued days of stay and reimbursement.
  1. Utilizing industry accepted utilization and or medical management criteria and can apply criteria to cases retrospectively to determine appropriateness of admission and days of stay, level of care, and over and under utilization.
  2. Demonstrates working knowledge about different industry criteria sets like Milliman, and InterQual.
  3. Demonstrates in depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs as well as commercial insurances and other types of plans: PPO, HMO, or indemnity.
  4. Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
  5. Assists with the preparations of denial notices given to patients.
  6. Reviews cases retrospectively when requested by finance department to determine if admission relates to continue care for Medicare.
  
  - Denial Management
  
  Coordinates the filing of appeals for clinical denials and works with other departments to ensure payment for care provided.
  1. Reviews denial letters and sends letters to other departments if appropriate.
  2. Communicates with attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
  3. Works with physician advisor to write appeal letters for denied care and sends letters to insurance companies.
  4. Documents denials in the BWH/MGB’s Denial Database.
  5. Follows up with insurance companies on claims status for clinical denials.
  
  - Team Work
  
  Assists with variety of functions and responsibilities of care coordination department to ensure that all state and federal mandates are followed. Participates in the ongoing evaluation of practice patterns and systems, support efforts to improve quality, cost and satisfaction outcomes.
  1. Expert on observation status and reviews observation patients as assigned.
  2. Assists in the completion of utilization reviews to insurers and intermediaries.
  3. Anticipates and troubleshoots claim and reimbursement issues.
  4. Assists in the review of Medicare reports as assigned.
  5. Participates in BWH and MGB’s Finance projects.
  6. Active Member of the ATO/Denial Committee and UR Committee.
  7. Other duties as assigned.

  
  

  Qualifications

  Education
  Bachelor's Degree Nursing required
  
  Can this role accept experience in lieu of a degree?
  Yes
  
  Licenses and Credentials
  Massachusetts Registered Nurse
  
  Experience

  • Previous experience in a hospital or health care setting required

  • Hospital utilization review and medical criteria sets required

  • Five years medical or surgical staff nurse experience required

  • Experience with leveling tool criteria required (such as InterQual or Milliman)

  
  Knowledge, Skills and Abilities
  - Strong clinical assessment skills, excellent interpersonal skills including ability to work collaboratively and cooperatively within a team and internal and external customers.
  - Strong organizational skills and ability to set priorities.
  - Ability to compile data from concurrent and retrospective medical review to determine clinical appropriateness, level of care and discharge plan; excellent written and verbal communication skills.
  - Computer skills.
  - Knowledge and skills to differentiate levels of care.

  
  

  Additional Job Details (if applicable)

  
  

  Remote Type

  Remote

  
  

  Work Location

  45 Francis Street

  
  

  Scheduled Weekly Hours

  40

  
  

  Employee Type

  Regular

  
  

  Work Shift

  Day (United States of America)

  
  

  EEO Statement:

  The Brigham and Women's Hospital, 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.

• About the company

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