New

Utilization Managment Nurse BWH

Brigham and Women's Hospital
United States, Massachusetts, Boston
45 Francis Street (Show on map)
Jul 08, 2025
The Insurance Support Nurse participates in the timely management of denials that are received in the Care Coordination Department. Through sound knowledge of utilization management, the nurse is able to assess a patient's level of care after review of the medical record. The nurse is a part of the care coordination staff and works closely with care coordination, medical and nursing staff to appeal denied claims and expedite appeal processes and case closure. The nurse works closely with admitting and finance staff, to process denied claims. For newly licensed nurses a Bachelor of Science Degree in Nursing is required. Does this position require Patient Care? No Essential Functions - Utilization Management Collaborates with appropriate individuals, departments and payers to ensure appropriateness of admission, continued days of stay and reimbursement. 1. Utilizing industry accepted utilization and or medical management criteria and can apply criteria to cases retrospectively to determine appropriateness of admission and days of stay, level of care, and over and under utilization. 2. Demonstrates working knowledge about different industry criteria sets like Milliman, and InterQual. 3. Demonstrates in depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs as well as commercial insurances and other types of plans: PPO, HMO, or indemnity. 4. Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances. 5. Assists with the preparations of denial notices given to patients. 6. Reviews cases retrospectively when requested by finance department to determine if admission relates to continue care for Medicare. - Denial Management Coordinates the filing of appeals for clinical denials and works with other departments to ensure payment for care provided. 1. Reviews denial letters and sends letters to other departments if appropriate. 2. Communicates with attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient. 3. Works with physician advisor to write appeal letters for denied care and sends letters to insurance companies. 4. Documents denials in the BWH/MGB's Denial Database. 5. Follows up with insurance companies on claims status for clinical denials. - Team Work Assists with variety of functions and responsibilities of care coordination department to ensure that all state and federal mandates are followed. Participates in the ongoing evaluation of practice patterns and systems, support efforts to improve quality, cost and satisfaction outcomes. 1. Expert on observation status and reviews observation patients as assigned. 2. Assists in the completion of utilization reviews to insurers and intermediaries. 3. Anticipates and troubleshoots claim and reimbursement issues. 4. Assists in the review of Medicare reports as assigned. 5. Participates in BWH and MGB's Finance projects. 6. Active Member of the ATO/Denial Committee and UR Committee. 7. Other duties as assigned. Education Bachelor's Degree Nursing required Can this role accept experience in lieu of a degree? Yes Licenses and Credentials Massachusetts Registered Nurse Experience Previous experience in a hospital or health care setting required Hospital utilization review and medical criteria sets required Five years medical or surgical staff nurse experience required Experience with leveling tool criteria required (such as InterQual or Milliman) Knowledge, Skills and Abilities - Strong clinical assessment skills, excellent interpersonal skills including ability to work collaboratively and cooperatively within a team and internal and external customers. - Strong organizational skills and ability to set priorities. - Ability to compile data from concurrent and retrospective medical review to determine clinical appropriateness, level of care and discharge plan; excellent written and verbal communication skills. - Computer skills. - Knowledge and skills to differentiate levels of care. The Brigham and Women's Hospital, 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.