Utilization Management Nurse (RN) - Harbor Health Services, Inc.

Offering a $5000. Sign On Bonus!*

Harbor Health Services is an innovative, growing, mission-based organization that lives, serves and collaborates with our community members to achieve our mission to help individuals reach their full potential through access to local, affordable services that promote health. Harbor provides medical, behavioral health, dental, and support services to more than 34,000 patients in Boston, the South Shore, and Cape Cod. In addition, Harbor Health operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly, a program that allows frail elders to live in their homes and communities.  Our Elder Service Plan has two medical and day centers in Mattapan and Brockton, MA and cares for more than 450 participants. We are currently seeking a talented Utilization Management Nurse to join our care teams at the Elder Service Plan. 

Harbor Health offers a comprehensive Benefits package including Health, Dental and Vision Insurance, generous Paid Time Off (PTO) plus 11 additional paid holidays and much more! Come join our great Elder Service Plan team! 

Role: 

Under the general direction of the Manager of Utilization Management and in collaboration with the Care Coordinators, the Utilization Management Nurse (UM RN) provides care coordination for a participant's hospital, long term acute care (LTAC), acute rehabilitation hospital, psychiatric or skilled nursing facility (SNF) stay. Working with the Interdisciplinary Care Team (IDT), the UM RN monitors the length of stay (LOS), the appropriate utilization of care, promotes quality, obtains clinical review, and plans/implements a participant’s discharge. 

Our ideal candidate would have strong experience in Utilization Management or Review, hospital discharge planning or Case Management. 

Responsibilities: 

• Responsible for the evaluation of the medical necessity of continuing acute inpatient or psychiatric stays, LTAC, acute rehabilitation and skilled nursing stays utilizing a defined criteria set.
• Utilizes clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
• Obtains the information necessary to assess a participant’s clinical condition, identifies ongoing clinical care needs and ensures that participants receive services in the most optimal setting to effectively meet their needs.
• Collaborates with ESP interdisciplinary teams regarding management of members not meeting continuing stay criteria.
• Anticipates member’s post-discharge needs, managing transition of care or referring to Care Coordinator when appropriate.
• Maintains mandated timeframes, including those related to second level appeals. 
• Uses Patient Ping (a real-time notification system that provides an alert when patients receive care in the ED, hospital or post-acute setting) to track participant disposition and work with providers to establish necessity of emergency room transfers. 
• Assists with clinical tasks/assignments as needed.

Requirements: 

• Bachelor's Degree in Nursing required
• Current, valid, and unrestricted MA Registered Nurse (R.N.) license and current BLS Certification required
• Minimum of 2-3 years of acute care clinical nursing experience required
• Minimum of 3 years of recent experience in Utilization Review / Utilization Management preferred
• 1-2 years of experience at a health plan or other Managed Care Organization (HMO/TPA/IPA/SCO, etc.) and/or experience in hospital discharge planning or Case Management preferred
• Experience using MCG/Milliman/InterQual criteria for medical necessity, setting and level of care, and concurrent patient management preferred
• Basic Computer skills to include Microsoft Word, Excel, database use, and data entry
• Must be able to travel between two or more sites and to outside contract agencies in a timely manner as needed

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

*Sign On Bonus offered, half on hire and remainder after 90 days in good standing, former employees of HHSI not eligible.