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Utilization Review Nurse

Company: Harvard Pilgrim Health Care
Location: Wellesley
Posted on: December 5, 2019

Job Description:

Are you interested in becoming part of a dynamic team that is looking to innovate and improve? Would you like to work for a company that has been rated by the BBJ (15 yrs) as one of the best places to work?Do you want to be part of a company that is committed to giving back to the community?Harvard Pilgrim Health Care is currently seeking highly motivated individuals to join our organization as Utilization Review Nurse. The Utilization Review Nurse will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review as well as complete determinations following physician review.WHAT YOU WILL BE DOINGServe a lead role in the review of requested medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining additional information required, and referral to correct departments.Assist in developing medical policies and procedures that directly impact member utilization of benefits.Perform clinical reviews to determine when services are medically necessary and appropriate; includes development and management of documentation standards to achieve maximum care management outcomes.Manage incoming requests for procedures and services including patient medical records and related clinical information.Develop and maintain effective working relationships with providers and as SME/Consultant for nurse care managers, ensure team compliance within department, and apply motivational interviewing techniques.Perform out-of-the-box thinking, collaborate with others, and make a difference every day!Other duties and projects as assigned.WHAT YOU NEEDRegistered Nurse (RN) with current state license, plus BSN or equivalent experience.5-8 years varied clinical experience, plus 1-2 yrs experience in a payer setting.Experience with clinical applications/systems. Excellent analytic, research, and problem solving skills.Excellent communication, organization, and interpersonal skills. Car and valid driver's license required.Resilient, collaborative, flexible, innovative.WHAT MAKES US STAND OUTWork-Life-FlexibilityPaid volunteer time off (up to 3 days annually)Open Time OffAnnual Mini-Grant of $500 donated to a non-profit organization of the employee's choiceEducational ReimbursementWorking EnvironmentVaries between HPHC offices and home office conditions and onsite work at various locations within HPHC service area. Travel may be required within the Harvard Pilgrim service area.DisclaimerThe above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position.

Keywords: Harvard Pilgrim Health Care, Boston , Utilization Review Nurse, Other , Wellesley, Massachusetts

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