Job Information
Tufts Medicine Utilization Specialist II in Burlington, Massachusetts
Our Integrated Network brings together a diversity of experienced private practice and employed physicians as well as community and academic providers. While we are one unified network, we focus on different geographic regions, with local care teams convening to ensure healthy, happy neighborhoods throughout the greater Boston region.
Job Overview
Ensures continuous, efficient and smooth flow of communication and administrative support activities for the Utilization and Case Management departments. This position is well versed in insurance coordination, financial counselling, and patient level of care. Interfaces with payers and communicates changes in level of care with the appropriate departments. Responsible for managing all UM clinical documentation.
Remote with occasional onsite requirements. Full time 8:30 AM - 5 PM Monday - Friday.
Job Description
Minimum Qualifications:
Bachelor’s degree in Nursing.
Massachusetts RN Licensure.
Obtain appropriate state board where services will be provided as a registered professional nurse OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) within three (3) months of hire.
Three (3) years hospital/health care experience in the area of Utilization Management.
Basic Life Support Certification OR Obtain within three (3) months.
Preferred Qualifications:
Five (5) years hospital/health care experience in the areas of Utilization Management with acute, subacute, home care, palliative care and hospice experience.
Case Management experience.
Case Management Certification.
Duties and Responsibilities : The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.
Manages clinical review process, including collaboration with inpatient and post- acute providers, leads UM meetings with Medical Directors.
Authorizes levels of care including Inpatient and SNF.
Manages and oversees peer to peer reviews including tracking reviews.
Scans all documents for future reference.
Coordinates continuity of care by addressing requests for discharge summaries.
Whenever possible creates computer files by scanning in lieu of paper files.
Provides assistance to case managers as needed.
Participates in team meetings and in quality improvement projects.
Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the working group’s achievement of goals, and to help foster a positive work environment.
Attends all necessary meetings.
Physical Requirements :
Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc.
This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending stairs and operate office equipment.
Frequently required to speak, hear, communicate and exchange information.
Able to see and read computers displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols.
Occasionally lift and/or move up to 25 pounds.
Skills & Abilities:
Knowledge of hospital and medical terminology and insurances.
Familiarity with the target community and feels connected to that community.
Excellent relationship management skills, including a high degree of psychological sophistication and non-aggressive assertiveness.
Demonstrated ability to problem solve complex, multifaceted, emotionally charged situations.
Excellent communication skills (telephonically and face-to-face).
Ability to work well with people of various ages, backgrounds, ethnicities, and life experiences.
A robust understanding of chronic health condition management and population management.
Motivational Interviewing proficiency.
Ability to prioritize and resolve critical issues efficiently and effectively.
Detail oriented, with strong organizational skills and multi-tasking abilities.
Very strong working knowledge and proficiency with technology and business software (Word, Excel, Outlook), e-mail and automated scheduling software and the ability to navigate through hospital-based computer systems.
Experience with Electronic Medical Records and possess a willingness and ability to learn and utilize new technology and procedures that will continue to develop in their role and throughout the organization.
Ability to work independently with minimal supervision and as part of a team.
Strong understanding of and ability to interact with various care settings, including post-acute settings, community-based options, and home care resources.
Proficient with InterQual criteria and guidelines.
Job Profile Summary
This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Care Manager related duties: Works as part of a multidisciplinary team to coordinate their patient's care in an effort to improve patient outcomes and create efficiencies. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. An experienced level role that applies practical knowledge of job area typically obtained through advanced education and work experience. Works independently with general supervision, problems faced are difficult but typically not complex, and may influence others within the job area through explanation of facts, policies and practices.
Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided 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. Please contact us to request accommodation by emailing us at careers@tuftsmedicine.org .