Lahey Health Supervisor Utilization Mgt - 40hrs in Winchester, Massachusetts
Welcome to Winchester Hospital, part of Beth Israel Lahey Health. Winchester Hospital was the first hospital in Massachusetts to earn Magnet recognition, the American Nurses Association’s highest honor for nursing excellence, three times. It has since received the recognition a fourth time. As the northwest suburban Boston area’s leading provider of comprehensive health care services, the 229-bed facility provides care in general, bariatric and vascular surgery, orthopedics, pediatrics, cardiology, pulmonary medicine, oncology, gastroenterology, rehabilitation, radiation oncology, pain management, obstetrics/gynecology and a Level IIB Special Care Nursery.
About the Job
JOB SUMMARY: Contributes to the Hospital’s mission by supporting proper classification and a safe plan of care. This professional licensed position will have an impact on finance and growth by classifying patients’ status appropriately and supporting a care plan to ensure the delivery of high quality, safe patient care while maintaining an expected length of stay within budget. This role functions in a high integrity manner and as a case management and utilization expert, collaborating interdepartmentally to educate and improve processes to appropriate classify patient status, which ultimately improves reimbursement. The Utilization Management Specialist will impact the patient experience and quality of care by daily rounding and working with the patient/family and provider to establish the best plan of care for discharge.
Education: Required: Bachelors of Science in Nursing
Prefered: Masters Degree in health care field.
· At least five (5) years of clinical experience as a Registered Nurse
· At least five (5) years of experience in inpatient case management and utilization review
· At least four (4) years of Leadership experience
· Experience in staff education in both the formal and non-formal setting presenting
· Certification in Case ManagementLICENSES, REGISTRATIONS, CERTIFICATIONS
Required : Current license to practice professional nursing from MA Board of Registration
Preferred: Professional certification
Function in a working supervisory role, overseeing the UM department which includes RN specialists and operational specialists.
Demonstrate the ability to partner with all colleagues and constituents in a positive and professional manner in order to sustain a high quality and high integrity workflow, yielding compliance with law, regulation, and payer requirements. Remain knowledgeable of all regulatory changes in order to determine the impact on Winchester Hospital. Take ownership for improvement initiatives as appropriate. Deep understanding of regulatory forms including IM's, MOON's, HINN's as well as the changing guidelines which dictate the use of the tools.
Assume responsibility for working appropriate work queues and reports, and oversee others who do the same, in order to sustain operational efficiencies and process measures.
Cross coverage for the Manager of Case Management as needed in her absence.
Demonstrated ability to partner with the interprofessional team regarding the patient plan of care and to establish reasonable goals. Applies diplomacy and professionalism when interacting with physicians and clinical staff, especially when addressing information required in order to carry out the patient plan in line with payer requirements
Proactively work with all payers as cases are reviewed, to ensure appropriate authorization and eligibility for services are secured.
Participates in analysis and trending of statistical data for specific patient populations to identify opportunities for improvement.
Manage the denial and appeal process, submitting needed documentation to the payer in a professional and timely manner.
Demonstrate presentation skills in order to lead meetings which involve the displaying of the UM data, performance measures, and plan.
Chair meetings as appropriate in an organized, well-prepared, and professional manner. Participate in both internal and external meetings as deemed appropriate by the manager, to improve hospital processes, measures, and outcomes. Demonstrate excellent verbal, written, and problem solving skills.
Demonstrates a commitment to service excellence, upholding all standards adopted by Winchester Hospital through our PROMISE program.
Demonstrate the ability to work with competing priorities in a manner that affords the ability to meet the overall expectations of the department and hospital.
Stay abreast of departmental issues and determine those which should be escalated in order to achieve resolution. Build new process flows as the needs of the organization change.
Work in a consultative manner with BILH constituents, providers, management, administration, billing, registration, medical records staff with regard to documentation, coding, reimbursement, and compliance matters.
Beth Israel Lahey Health is an integrated system providing patients with better care wherever they are. Care informed by world-class research and education. We are doctors and nurses, technicians and social workers, innovators and educators, and so many others. All with a shared vision for what healthcare can and should be. We are committed to attracting, developing and retaining top talent. We strive to create a diverse and inclusive workplace that reflects the communities in which we work and serve. With a team approach to care, we encourage learning and growth at all levels and offer competitive salaries and benefits.
Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.
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