DSNP Utilization Management Nurse

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

The D-SNP UM Case Manager, RN performs utilization management activities primarily for D-SNP (OneCare and Senior Care Options), including review of integrated organization determinations for outpatient, inpatient, post-acute, and long-term services and supports (LTSS) following CMS and EOHHS regulations.

Qualifications

Education

Associate's Degree Nursing required; Bachelor's Degree Nursing preferred

Licenses and Credentials

• Massachusetts Registered Nurse license required
  Basic Life Support (BLS Certification) Certification preferred

Experience

• At least 2-3 years of utilization management strongly preferred
• Experience applying National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and LTSS guidelines highly preferred
  InterQual experience preferred

Knowledge, Skills, and Abilities

• Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
• Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
• Ability to establish strong rapport and relationships with patients and staff.
• Proficient in Microsoft Office and industry related software programs.
• Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
• Ability to maintain client and staff confidentiality.
• Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
• Knowledge of Healthcare and Managed Care preferred.

Additional Job Details (if applicable)

Working Conditions

• This is a remote role that can be done from most US states

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$58, $142,448.80/Annual

Grade

98TEMP

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into