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Fallon Health Utilization Management Nurse in Worcester, Massachusetts


About Fallon Health:

Fallon Health is a mission-driven not-for-profit health care services organization based in Worcester, Massachusetts. For 45 years we have been improving health and inspiring hope in the communities we serve. Committed to caring for those who need us most, we pride ourselves on providing equitable access to coordinated, integrated care for our members with a special focus on those who qualify for Medicare and Medicaid. We also serve as a provider of care through our Program of All-Inclusive Care for the Elderly (PACE). Dedicated to delivering high quality health care, we are continually rated among the nation’s top health plans for member experience and service and clinical quality.

Brief Summary of Purpose:

The UM Nurse uses a multidisciplinary approach to organize, coordinate, monitor, evaluate and modify plans of care and/or service requests, focusing on selected complex medical and psychosocial needs of FH members and their families. The UM Nurse is responsible for assuring the receipt of high quality, cost efficient medical outcomes for enrollees. This role works with Medical Directors, Authorization Coordinators and Service Coordinators to perform first level review to pre-certify elective services, procedures and tests utilizing established Care Coordination polices and protocols, Fallon Health benefit criteria, applicable regulatory review criteria and nationally accepted criteria for medical necessity determination.


Job Responsibilities:

Utilization Review:

  • Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services.

  • Oversee utilization management decisions completed by Senior Nurse Case Managers to ensure decisions are appropriate and identify and implement corrective action as needed.

  • Conducts clinical reviews of proposed services against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status.

  • Work with Medical Directors, Program Leadership and Fallon Health Provider Relations to identify and mitigate facility barriers associated with the ability to make timely decisions.

  • Identify, align and utilize health plan and community resources that impact high-risk/high-cost care.

  • Act as liaison between assigned facilities, members/families, and Fallon Health. Clarify policies/procedures and member benefits as needed. Authorizes services, coordinates care, and ensures timeliness and coordination of healthcare services, in compliance with department and regulatory standards, seeking supplemental services when appropriate or when needed.

  • Assess enrollee needs and monitor progress toward goals at all times, communicating findings and status with members of the enrollee’s primary care team.

  • Ensure optimal delivery of safe quality health care to members, while maximizing resources and containing costs, and facilitate continual patient-centered and outcome-driven health performance improvement activities.

  • Create contingency plans to anticipate treatment and service complications, while ensuring that the enrollee attains pre-determined outcomes.

  • Review enrollees with the Medical Directors and Primary Care Teams and advocates for Administration Exception considerations as appropriate.

Dischard Planning:

  • Facilitate communications between the facility, providers, and the PCT in order to effect and influence a safe and effective discharge plan and care plan for the enrollee.

  • Initiate the episodic plan of care that facilitates initation of the discharge plan for the inpatient or SNF setting.

  • Work with facility case management department or specifically assigned staff to develop appropriate discharge plans; implements and continually reassesses the discharge plan.

  • Collaborate with facilities, clinical team members and others involved in enrollee plan of care to ensure a smooth transition from facility to home setting for both assigned facility admissions and for program overall.

Clinical data management, analysis and reporting:

  • Document clinical, functional, psychosocial information in the case management software system or Fallon Health core system. Facilitate communications regarding members’ care with PCT Team and family members.

  • Identifies utilization trends or processes to Supervisor or Manager and supports the implementation of improvements.

  • Review clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate.

  • Maintain accurate records of all interventions and provide timely verbal and written reports to PCT staff and associated family members as directed.

  • Issue regulatory and other letters according to policies and procedures.

  • Requests and obtains relevant clinical information from medical care providers as needed for the clinical review process.

Monitors compliance:

  • Follow the Case Management Standards of Practice, Ethicial standards, department policies and procedures, and compliance regulations.

  • Strictly observices HIPPA regulations and the Fallon Health polices regarding confidentiality of enrollee information, documentation standards, meeting any education requirements, etc.

  • Refer cases to medical review according to policy and procedure.

Provides training and project management:

  • Ensure Senior Nurse Case Managers are prepared and able to present enrollee data during rounds and huddles appropriately, teaching and mentoring as appropriate.

  • Orients, precepts, and trains Senior Nurse Case Managers to ensure they are able to apply ocverage criteria in an appropriate manner.

  • Supports department colleagues, covering and assuming changes in assignment as assinged by Clinical Manager/Designee.

  • Acts as a resource to Authorization Coordinators:processes and /or consults on authorizations, as appropriate

  • Participates in special projects including but not limited to training new team members, participating in projects related to software programs and others as assigned assoicated with the UM role and function.



Graduate from an accredited school of nursing, or Bachelors (or advanced) degree in nursing, or Rehabilitative Services (i.e. Physical or Occupational Therapy) required


Active and unrestricted licensure as a Registered Nurse in Massachusetts.


  • A minimum of three to five years clinical experience as a Registered Nurse in a clinical setting required.

  • 2 years’ experience as a Utilization Management nurse in a managed care payer preferred.

  • One year experience as a case manager in a payer or facility setting highly preferred.

  • Discharge planning experience highly preferred.

F allon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Location US-MA-Worcester

Posted Date 2 months ago (1/31/2023 11:32 AM)

Job ID 7186

# Positions 1

Category Nursing