Registered Nurse; RN - Utilization Review

Framingham, MA, United States (On-site)

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Position Summary:

The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis.

This position integrates national standards for case management scope of services including:
Utilization Management services supporting medical necessity and denial prevention;
Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient;
Compliance with state and federal regulatory requirements, TJC accreditation standards, and Tenet policy; and Education provided to payers, physicians, hospital/office staff, and ancillary departments related to covered services and administration of benefits.

• Responsible for providing accurate medical necessity screening and submission for Physician Advisor review.
• Securing and documenting authorization for services from payers as well as managing concurrent disputes.
• Collaborating with payers, physicians, office staff, and ancillary departments.
• Maintenance of accurate patient demographic and insurance information.
• Identification and documentation of potentially avoidable days & reporting over and under utilization
• Performs related duties as assigned

Required

• Education:Graduate of an accredited school of nursing
• Experience:2 years of acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting
• Certification:
  • RN.
  • Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy.
  • Active RN license for state(s) covered.

Preferred

• Education:Academic degree in nursing (bachelor's or master's)

Join our dedicated healthcare team where compassion meets innovation! As a Registered Nurse with us, you'll have the opportunity to make a meaningful impact in patients' lives while enjoying a supportive work environment that fosters professional growth and work-life balance. Ready to be a vital part of our mission? Apply today and bring your passion for nursing to a place where it truly matters!

At Metrowest Medical Center - Consolidated, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note:
Eligibility for benefits may vary by location and is determined by employment status

Metro West Medical Center has been serving the community since we opened as the first public medical facility in Framingham in 1893. Metro West Medical Center is comprised of Framingham Union Hospital and Leonard Morse Hospital, a unique behavioral health specialty center located in Natick dedicated to the mental health of our community. At Framingham Union Hospital, youll find comprehensive health care services for the entire family including 24-hour emergency care, advanced cardiac care, high-tech cancer treatments and advanced maternity…