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Wellforce Utilization Review RN Manager in Lowell, Massachusetts

Position Summary:

Under the supervision of the Director of Healthcare Operations, the Utilization Review RN Manager will work to improve transitions of care and ensure care is being delivered in the most appropriate setting for Medicare MSSP/Medicaid patients. The Utilization RN Manager will work closely with the COC care management teams, hospital staff, Patient Ping, and the Community Partners to monitor utilization of services by MSSP/Medicaid patients, identify medical and social drivers of ED utilization, and respond appropriately. The Utilization RN Manager will work to improve the quality of care by reviewing clinical information and recommending the most appropriate care setting in collaboration with facility clinical staff, patients, families, and physicians. Using effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions, the RN Manager will:

  • Promote improved quality of care and/or life

  • Promote cost effective medical outcomes

  • Prevent hospitalization when possible and appropriate

  • Promote decreased lengths of hospital stays when appropriate

  • Provide for continuity of care

  • Assure appropriate levels of care are received by patients

  • Ensure appropriate transitions of care, including connections with community & home care services

  • Ensure post-discharge follow up by Community Partner care teams and PCPs

    Duties & Responsibilites:

  • Improve transitions of care, identify drivers of utilization and prevent avoidable utilization.

  • Monitor utilization through Patient Ping and hospital EMRs.

  • Divert unnecessary ED admissions, as appropriate.

  • Assist with case management in ED, including the arrangement of prompt outpatient follow up, direction to a SNF or other facility.

  • Build relationships Involved in hospital discharge planning to steer patients to appropriate post-acute facility (acute vs. subacute rehab, preferred SNF network, etc.)

  • Monitor discharges from outside hospitals/tertiary facilities to ensure proper local f/u post discharge.

  • Will work with ACO Community Programs RN Manager and Director of Case Management to create innovative programs—such as mobile unit for the homeless population, ED diversion programs, clinical navigators.

  • Provide appropriate consultation and referral to Case Management teams.

  • Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources to meet medical and social determinants of health.

  • Maintain accurate records of all interventions and provide timely verbal and written reports, as directed by the Director of Case Management.

  • Prepare monthly management reports.

  • Maintain accurate records of all communications and interventions.

    Qualifications:

  • Bachelor's Degree

  • Registered nurse with an active professional Massachusetts license

  • Two years of prior experience with Utilization Management.

  • 3-5 years of clinical experience in an acute care or post-acute care setting

  • Home care, Case Management, or Managed Care Programs experience is a plus

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