Community Health Center/Community Clinic, Home Health Care Provider, Public Health
Under the general direction of the Manager of Utilization Management and in collaboration with the Care Coordinator at the Elder Service Plan of Harbor Health, the Utilization Management Nurse (UM RN) provides care coordination for a patient's hospital, long term acute care (LTAC), acute rehabilitation hospital, psychiatric or skilled nursing facility (SNF) stay. Working with the Interdisciplinary Care Team (IDT), the UM RN monitors the length of stay (LOS), the appropriate utilization of care, promotes quality, obtains clinical review, and plans/implements a participant’s discharge. Some of work assignment can be done remotely.
Responsible for the evaluation of the medical necessity of continuing acute inpatient or psychiatric stays, LTAC, acute rehabilitation and skilled nursing stays utilizing a defined criteria set.
Utilizes clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
Responsible for obtaining the information necessary to assess a participant’s clinical condition, identifies ongoing clinical care needs and ensures that participants receive services in the most optimal setting to effectively meet their needs.
Collaborates with ESP interdisciplinary teams regarding management of members not meeting continuing stay criteria.
Anticipates member’s post-discharge needs, managing transition of care or referring to Care Coordinator when appropriate.
Maintains mandated timeframes, including those related to second level appeals.
Uses Patient Ping (a real-time notification system that provides an alert when patients receive care in the ED, hospital or post-acute setting) to track participant disposition and work with providers to establish necessity of emergency room transfers.
Required/Preferred Education, Experience and Skills:
Bachelor's Degree in Nursing required.
Current, valid, and unrestricted MA Registered Nurse (R.N.) license.
Minimum of 2-3 years of acute care clinical nursing experience required.
Minimum of 3 years of recent experience in Utilization Review / Utilization Management preferred.
1-2 years of experience at a health plan or other Managed Care Organization (HMO/TPA/IPA/SCO, etc.) preferred.
Experience using MCG/Milliman/InterQual criteria for medical necessity, setting and level of care, and concurrent patient management preferred.
Basic Computer skills to include Microsoft Word, Excel, database use, data entry and Electronic Medical Record.
Harbor Health is an Equal Opportunity Employer M/F/V/D.
Additional Salary Information: Based on experience
Internal Number: 1487
About Harbor Health Services - Elder Service Plan
Harbor Health Services Inc. is a non-profit public health agency located in Massachusetts with a mission to help individuals achieve their full potential through access to local, affordable services that promote health. Harbor provides medical, behavioral health, dental, and support services to more than 34,000 patients in Boston, the South Shore, and Cape Cod.
Harbor Health operates five community health centers:
-Geiger Gibson Community Health Center – the first community health center in the U.S. founded in 1965!
-Daniel Driscoll – Neponset Health Center
-Harbor Community Health Center-Plymouth
-Harbor Community Health Center-Hyannis
-Ellen Jones Community Dental Center – Dennis
In addition, Harbor Health operates two Programs of All-Inclusive Care for the Elderly, a program that allows frail elders to live in their homes and communities, as well as the Dorchester South/South Boston Women, Infants, and Children (WIC) Nutrition Program.
Our Elder Service Plan has two medical and day centers in Mattapan and Brockton, MA and cares for more than 450 participants. Our WIC program provides services at Harbor’s Dorchester locations, as well as at other community health center and mobile locations. WIC serves more than 3,000 women and their children each year.