Case Manager,Per Diem Job Marlborough area,Massachusetts USA,Healthcare

Are you an internal caregiver, student, or contingent worker/agency worker at UMass Memorial Health? to apply through your Workday account.

Exemption Status: Non-Exempt

Hiring Range: $39.25 - $70.65

Please note that the final offer may vary within this range based on a candidate’s experience, skills, qualifications, and internal equity considerations
.

Schedule Details: Monday through Friday, Weekends (Saturday and Sunday)

Scheduled

Hours:

8am-4:30pm

Shift: 1 - Day Shift, 8 Hours (United States of America)

Hours: 0

Cost Center: 21000 - 4402 Case Management

This position may have a signing bonus available; a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver—regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading‑edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other.

And everyone, in their own unique way, plays an important part, every day.

Under the supervision of the Director of Case Management, the Case Management/Utilization Review Coordinator is an experienced clinical case management professional with responsibility for monitoring and maintaining appropriate hospital wide utilization review. Combines clinical, business and regulatory knowledge and skill to ensure appropriate utilization of care, promote optimal billing, insurance benefit use and regulatory compliance and prevent significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided.

Collaborates with physician, case managers, revenue cycle personnel and payers to appeal denials. Performs activities related to the utilization management process, including conducting a denial appeals process that includes monitoring for patterns and trends and maximizing reimbursement within regulatory requirements. Works directly with Case Management team to ensure that clinical operations related to care leveling are timely and accurate. Reviews the work of Case Managers related to Utilization Review and makes determination of appropriate level of care based on clinical knowledge and judgment as a first level reviewer.

Identifies opportunities for improved documentation of Utilization Review assessment and maintains responsibility for follow through throughout the patient hospital stays. Maintains responsibility for teaching and assessing competency of Case Management staff related to level of care applications.

Major Responsibilities

Maintains responsibility for the coordination and submission of appeals to third party payers within allotted time frames to prevent fiscal penalties

Is the key contact person for all Medicare RAC denials and processes each denial following the established framework

Meets with the Case Managers to review the medical record to gather missing supportive documentation to strengthen the appeals process

Maintains dialogue with payers about disputed claims and maintains documentation of ongoing efforts for each disputed claim

Assists in the writing of draft appeal letters and prepares and edits the final documents prior to submission to the third‑party payer

Position Qualifications

Licensure/Certification /

Education:

Current Massachusetts licensure of RN

Graduate of an accredited school of nursing

BS required

Experience/

Skills:

Minimum 7‑10 years relevant experience including UR/Case management in the acute care setting

Expert working knowledge of all applicable level of care criteria applications—both written and electronic

Expert in Inter Qual criteria—maintains level of expertise to be hospital wide trainer

Comprehensive proficiency in the case management role, including direct patient interaction and care planning

Expert knowledge of current reimbursement models:
Commercial, managed care, Medicare, Public Assistance

Excellent interpersonal communication and negotiation skills with…


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Case Manager, Per Diem