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Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.

Minimum - Midpoint - Maximum

$96,137.00 - $110,510.00 - $130,728.00

UM Regulatory Nurse Specialist - Baystate Health, Health New England

This is a **full-time remote opportunity** . Current States Eligible MA and CT

The **UM Regulatory 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. 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. 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:

+ Pre-authorization reviewutilizingcriteria todetermineappropriateness of requested services

+ Admission reviewutilizingcriteria todetermineappropriateness of inpatient admission

+ Concurrent reviewutilizingcriteria todetermineappropriateness of continued stay andappropriate levelof care

+ Retrospective reviewutilizingcriteria todetermineappropriateness of requested service/level of care

+ Proactive discharge planning to ensure members’ needs are met throughout the continuum of care

+ Performsresearch to obtain necessary clinical information for decision making

+ Ensuresappropriate timeliness,guidelines,and proper notification standards are met

Coordination of Care functions

+ Assistsmembers and providers with transition of care, referral management, care coordination, and benefit management

+ Makesappropriate referralswithin CSI team as well as to external resources, such as amembersPCP to maximize positive member outcomes asper HNE policies and processes

+ Contributesto enhancement of services -existing and new- byparticipatingon workgroups, clinical initiatives, service initiatives, quality initiatives, and others as assigned

+ Assistswith creation and revision ofdepartmental Policy & Procedures

+ Processes Member and Provider appeals

+ Effectively utilizesHNE UM/CM/DM policies and processes, and electronic systems

+ Participateswith off-site visits to in-plan facilities and providers

Compliance Education, Training, and Communication

+ 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 smallerinformal sessions as directed

+ Monitorsand updatesSupportPointas needed

Compliance Regulatory Filings and Audits

+ Coordinatescompliance 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, andMassHealth, including but not limited to renewal applications for HMO Accreditation, License, and Mental Health Parity certification for Commercial andMassHealth. In addition, the Health Services Compliance Specialist willbe responsible forHSparticipation 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

Required Education/Experience:

+ Massachusetts RN license required

+ 3-5 years’ experience as a UM Clinical Review Nurse for a Health Plan

+ Understanding of the use of medical coding

+ Strong critical thinking skills

+ Innovative thinker

+ Strong analytical and research skills

Preferred Experience

+ Certified Professional Coder Certification coding

+ Direct experience in Staff Education

+ Innovative thinker

+ Strong analytical and research skills

THE ADVANTAGES OF WORKING WITH BAYSTATE!

+ Excellent Compensation High-quality, low-cost medical, dental and vision insurance

+ Generous PTO

+ Continuing education support and reimbursement

+ Wellbeing programs that include but are not limited to mental, physical, and financial health

+ Pet, home, auto and personal insurance

+ Life insurance

+ Reimbursement for a variety of wellbeing activities, included but limited to gym membership and equipment, personal trainer, massage and so much more!

About Health New England

Based in Springfield, Massachusetts, part of Baystate Health, Health New England is a regional not-for-profit health plan serving over 160,000 members in central and western Massachusetts and parts of Connecticut. Health New England has been meeting the health care needs of its members for nearly 40 years. Health New England is committed to improving the health and lives of people of our community, both in our workplace and for our members. We are committed to creating opportunities for individuals of all backgrounds to grow and thrive.

Education:

Bachelors Degree

Certifications:

Registered Nurse - State of Massachusetts

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.