DSNP Utilization Management Nurse

The D-SNP UM Case Manager, RN performs utilization management activities primarily for D-SNP (One Care 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.

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

• Massachusetts Registered Nurse license required
• Basic Life Support [BLS Certification] Certification preferred

• 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
• Inter Qual experience preferred

• 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.

• Remote role that can be done from most US states

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.