Registered Nurse; RN - Clinical Support Specialist

Tenet Massachusetts is seeking a Registered Nurse (RN) Clinical Support Specialist for a nursing job in Framingham, Massachusetts.

• Specialty:
  Clinical Support Specialist
• Discipline:
  RN
• Duration:
  Ongoing
• 36 hours per week
• Shift:
  12 hours, days
• Employment Type:
  
  Staff

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)
• Certification: Accredited Case Manager (ACM)

Tenet Mass Job  #. Posted job title:
Registered Nurse (RN) - Utilization Review

Facilities:

Saint Vincent Hospital – Worcester, MA

Metro West Medical Center – Framingham, MA

Leonard Morse Hospital – Natick, MA (part of MWMC)

MA - SVH

Tenet’s Saint Vincent Hospital has been providing high-quality health care to Worcester and the surrounding communities for more than 125 years. At Saint Vincent Hospital, we believe you should have access to the treatments you need without having to travel far from home. We are proud to have been the first hospital in central Massachusetts to offer robotically assisted surgical procedures and minimally invasive, computer-assisted joint replacements.

Among the distinctions that we have received include our designations as a Blue Distinction Center for

Cardiac Services, Bariatric Surgery, and both Knee and Hip Replacement. We continue to be leaders in state-of-the-art treatments like our Cyber Knife Radiosurgery, and our Cardiac Rehabilitation Program which offers a unique, specialized approach to overcoming heart health challenges. Health grades awarded Saint Vincent Hospital #1 in Cardiology in the state and one of America’s 100 Best Hospitals for Coronary Intervention in 2023 and 2024, which puts Saint Vincent Hospital in the top 5% of hospitals nationwide for coronary intervention.

At Saint Vincent Hospital, you can grow your career skills through a wide range of specialties, and help support the overall health of our community.

MA - MWMC

Tenet’s Metro West Medical Center has been serving the community since we opened as the first public medical facility in Framingham in 1893.…