UM Regulatory Nurse Specialist

Overview

Note:

The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range.

Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.

UM Regulatory Nurse Specialist - Baystate Health, Health New England

This is a full-time remote opportunity
. Current States Eligible MA and CT

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 to 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 provides guidance, conducts reviews or monitors 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.

• Performs research to obtain necessary clinical information for decision making
• Ensures appropriate timeliness, guidelines, and proper notification standards are met

Coordination of Care functions

• Contributes to enhancement of services - existing and new - by participating on work groups, clinical initiatives, service initiatives, quality initiatives, and others as assigned
• Assists with creation and revision of departmental Policy & Procedures
• Processes Member and Provider appeals
• Effectively utilizes HNE UM/CM/DM policies and processes, and electronic systems

• 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
• Monitors and updates Support Point as needed

• Coordinates compliance and regulatory responses with the HNE Compliance Department when addressing filings for MCO as required by Commonwealth of MA, Division of Insurance, Federal Healthcare Administration, and Mass Health, including but not limited to renewal applications for HMO Accreditation, License, and Mental Health Parity certification for Commercial and Mass Health. In addition, the Health Services Compliance Specialist will be responsible for HSO participation in the ODAG annual audit as well as the CMS Mock Audit, coordinating reporting and gathering all pertinent documentation and oversight of any necessary re-training for the HS team

• 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
• St…