Nurse Specialist bei Health New England

SUMMARY:  Utilization review:  The Nurse Specialist is responsible for delivering medical or behavioral health utilization management (UM) and coordination of care services to members in compliance with current accreditation requirements and quality standards, and within the scope of the members’ benefit package and per HNE policies. Supports the HNE mission by developing partnerships with and providing personal and accountable service to members and providers. Impacts positive health outcomes for members and positive financial outcomes for HNE. Keeps abreast of professional standards, new technologies and proactively seeks out new learning.

Compliance and Coding:  The Nurse Specialist will assist the Utilization Management Department with developing, implementing, and maintaining the compliance program and compliance risk management efforts for Health New England (HNE) as they pertain the Utilization Management and Case/Disease Management. This position will also manage all requirements around coding review for the department.  This position works to ensure that HNE operates within the policies, procedures, and regulations set forth by HNE and by state and federal laws, including HIPAA, Medicare, and Medicaid.  A comprehensive knowledge of policies and procedures related to state and federal regulations is required.  This position will work closely with the HNE Compliance Department who providers guidance, conducts reviews or monitor potential issues noted in the annual risk assessment and/or annual work plan.  This position will operate as a HS liaison with various departmental stakeholders, including Legal, Government Programs, Complaints & Appeals and Quality.

ESSENTIAL FUNCTIONS:

Performs UM and coordination of care as per HNE policies and processes including but not limited to UM functions – 50% 

• Pre-authorization review utilizing criteria to determine appropriateness of requested services
• Admission review utilizing criteria to determine appropriateness of inpatient admission
• Concurrent review utilizing criteria to determine appropriateness of continued stay and appropriate level of care
• Retrospective review utilizing criteria to determine appropriateness of requested service/level of care
• Proactive discharge planning to ensure members’ needs are met throughout the continuum of care
• Performs research to obtain necessary clinical information for decision making
• Ensures appropriate timeliness, guidelines, and proper notification standards are met

 Coordination of Care functions

• Assists members and providers with transition of care, referral management, care coordination, and benefit management
• Makes appropriate referrals within CSI team as well as to external resources, such as a members PCP to maximize positive member outcomes as per HNE policies and processes
• Contributes to enhancement of services -existing and new- by participating on workgroups, clinical initiatives, service initiatives, quality initiatives, and others as assigned
• Assists with creation and revision of departmental Policy & Procedures
• Processes Member and Provider appeals
• Effectively utilizes HNE UM/CM/DM policies and processes, and electronic systems
• Participates with off-site visits to in-plan facilities and providers

 Code Review – 10% 

• Oversees the annual code review as well as any code changes and code load activities throughout the year
• Evaluates if codes are covered or not covered per LOB and determines which codes are to be presented to the Preventative Code Committee and MTAC
• Primary point of contact for Configuration, Claims and Appeals for all code-related inquiries.  This includes performing research, making coverage recommendations and assistance with determining pricing

 Compliance Education, Training, and Communication – 5%

• Develops and coordinates general compliance educational activities as directed by the Compliance Department as they relate to Health Services. This includes preparing educational materials for annual compliance training requirements and for smaller informal sessions as directed
• Monitors and updates SupportPoint as needed

 HNE Policies, Procedures, and Other Documentation – 10% 

• Ensures policies, practices and protocols are compliant and implemented and documented as required
• Maintains, reviews, and approves documentation in a timely manner

 Metrics and Reporting – 5%

• Designs and implements metric programs and reporting tools to communicate compliance incidents, education and training, policies and procedures, and other related results and activities to all appropriate parties, including the HNE Compliance Department

 Compliance 360 Analysis – 5%

• Responsible for business process analysis and detailed specification development in order to ensure Health Services is meeting all requirements.  This includes managing requests received via C360 related, working with internal and external customers to ensure new or updated NCD are reviewed and follow-up is performed as indicated

 Compliance Incidents and Investigations – 5%

• Works with the Compliance Department and assists with their investigations to ensure all complaints and concerns regarding healthcare compliance, HIPAA privacy and security, and compliance risks are handled appropriately and in a timely manner

 Compliance Regulatory Filings and Audits – 5%

• Coordinates compliance and regulatory responses with the HNE Compliance Department when addressing filings for MCO as required by Commonwealth of MA, Division of Insurance, Federal Healthcare Administration, and MassHealth, including but not limited to renewal applications for HMO Accreditation, License, and Mental Health Parity certification for Commercial and MassHealth.  In addition, the Health Services Compliance Specialist will be responsible for HS participation in the ODAG annual audit as well as the CMS Mock Audit, coordinating reporting and gathering all pertinent documentation and oversight of any necessary re-training for the HS team

 Delegation Oversight – 5%

• Monitors and tracks requirements around UM delegated entities, to include but not limited to CMS-Medicaid-DOI-NCQA contract requirements for auditing, review of updates or changes to existing processes, compliance attestations and letter review

 Other essential functions

• Adheres to departmentally established productivity standards
• Maintains collaborative and helpful working relationships with internal and external customers
• Participates in the On-call program as well as flexible work hours as needed within the department

MINIMUM REQUIREMENTS:

Bachelor’s degree and a current license in a clinical specialty as a Registered Nurse,
Social Worker, or Behavioral Health professional with 3 - 5 experience as a case/care manager, utilization management nurse, home care, or hospital setting; or an equivalent combination of education and experience. 

• Coding experience required 
• Certified Professional Coder preferred 
• Computer literacy (including Microsoft Office Suite) and ability to navigate through computer systems required 
• Excellent written and verbal communication skills including the willingness to deliver
  presentations 
• Sound clinical assessment and decision-making skills, and highly ethical 
• Excellent critical thinking, problem solving and organizational skills, with attention to detail 
• Ability to understand and interpret state and federal laws and regulations 
• Ability to apply legal/compliance rules to practical daily operations 
• Excellent time management skills and ability to manage multiple priorities 
• Ability to work independently and manage an assigned caseload 
• Strong teamwork skills; ability to work collaboratively with team members 

• Occasionally lifts weights up to 25 lbs.
• Occasional travel is required for workshops, seminars and meetings several days-and evenings-throughout the year