UM Regulatory Nurse Specialist, Health England

Position: UM Regulatory Nurse Specialist, Health New England
The
** UM Regulatory Nurse Specialist
** is responsible for delivering medical or behavioral health utilization management (UM) and coordination of care services to members in compliance with current accreditation requirements and quality standards, and within the scope of the members’ benefit package. Supports the HNE mission by developing partnerships with and providing personal and accountable service to members and providers. Impacts positive health outcomes for members and positive financial outcomes.

Keeps abreast of professional standards, new technologies and proactively seeks out new learning. :  The Nurse Specialist will assist the Utilization Management Department with developing, implementing, and maintaining the compliance program and compliance risk management efforts for Health New England (HNE) as they pertain the Utilization Management and Case/Disease Management. This position will also manage all requirements around coding review for the department.  

This position works to ensure that HNE operates within the policies, procedures, and regulations set forth by HNE and by state and federal laws, including HIPAA, Medicare, and Medicaid.  A comprehensive knowledge of policies and procedures related to state and federal regulations is required.  This position will work closely with the HNE Compliance Department who providers guidance, conducts reviews or monitor potential issues noted in the annual risk assessment and/or annual work plan.

This position will operate as a HS liaison with various departmental stakeholders, including Legal, Government Programs, Complaints & Appeals and Quality.

Compliance Education, Training, and Communication  Develops and coordinates general compliance educational activities as directed by the Compliance Department as they relate to Health Services. This includes preparing educational materials for annual compliance training requirements and for smaller informal sessions as directed
** Required Education/

Experience:

*** Massachusetts RN license required
* 3-5 years’ experience as a UM Clinical Review Nurse for a Health Plan
* Understanding of the use of medical coding
* Strong critical thinking skills
* Innovative thinker
* Strong analytical and research skills
** Preferred Experience
*** Certified Professional Coder Certification coding
* Direct experience in Staff Education
* Innovative thinker
* Strong analytical and research skills
** THE ADVANTAGES OF WORKING WITH BAYSTATE!
*** Excellent Compensation High-quality, low-cost medical, dental and vision insurance
* Generous PTO
* Continuing education support and reimbursement
* Wellbeing programs that include but are not limited to mental, physical, and financial health
* Pet, home, auto and personal insurance
* Life insurance
* Reimbursement for a variety of wellbeing activities, included but limited to gym membership and equipment, personal trainer, massage and so much more!
** About Health New England
** Based in Springfield, Massachusetts, part of Baystate Health, Health New England is a regional not-for-profit health plan serving over 160,000 members in central and western Massachusetts and parts of Connecticut. Health New England has been meeting the health care needs of its members for nearly 40 years. Health New England is committed to improving the health and lives of people of our community, both in our workplace and for our members.

We are committed to creating opportunities for individuals of all backgrounds to grow and thrive.
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