Behavioral Health RN Care Coordinator

Heywood Medical Group; Gardner, Northern (MA, KY); Hybrid; USD 55,000 - 109,000; Full time

Job summary

Heywood Healthcare is seeking a Per Diem Registered Nurse to join Utilization Management in Massachusetts. The role focuses on utilization review, care transitions, and coordination with payers to support timely authorizations and appropriate care.

Responsibilities include discharge planning participation, documentation of medical necessity, and collaboration with the Behavioral Health team to optimize patient flow and ensure quality outcomes. MA RN license and UR/QA experience are preferred.

Qualifications

• BSN preferred.
• RN with Massachusetts license required.
• UR/QA experience required.
• 2 years of healthcare experience within Behavioral Health and/or Insurance industry preferred.

Responsibilities

• Utilization Review and Care Transitions & Coordination with payers.
• Discharge planning participation and care coordination.
• Review medical necessity and ensure timely authorizations and documentation.
• Collaborate with BH team to address discharge needs and patient education.

Skills

Utilization Management

Discharge Planning

Communication

Documentation

Education

BSN preferred

Job description

Overview

You Matter Here!

Heywood Healthcare values our employees! We offer competitive wages, great benefits and generous earned time off. Come work where you will matter!

Hours: Per Diem, day shift, no weekends/holidays

$39.58-78.93

Disclaimer:

We are committed to equitable and transparent compensation practices. The salary range for this position reflects our good-faith estimate of base pay at the time of posting. Final compensation will be determined based on a variety of factors, including relevant experience, skills, qualifications, and internal equity. We regularly review our compensation structures to ensure fairness and consistency across our organization.

Responsibilities

Essential Functions

• Utilization Management - Utilization Review and Care Transitions & Coordination
  • Providing clinical information to payers, monitoring length of stay, seeking necessary care authorizations and appealing denials as indicated within a timely fashion.
  • Follows-up on lack of documentation for medical necessity, supporting documentation with discipline identified.
  • Track and trend opportunities for improvement resulting in late Insurance Reviews, longer lengths of stay
  • Completes utilization reviews daily and/or as required by insurer, (concurrent and retro) for psychiatric appropriateness according to Hospital's approved criteria timely and efficiently.
  • Demonstrates clinical expertise specific to the issuance of ABN/HINN notice to patients and/or legal significant other and care progression. Responsible for insurance interactions related to Medicare Important Message appeal process. Keeping physician and team informed of status change and documenting status.
  • In collaboration with the BH Clinical Team provides education and information to patient, family and care providers as it pertains to continuing care, care management, LOS, re-hospitalization and assure understanding of disease management.
• Multidisciplinary Team Rounds -
  • Participates in discharge planning teams daily.
  • Works collaboratively with multidisciplinary team to determine each patient's needs concurrently including post-acute care when needed; addresses LOS issues, appropriate leveling of patient status; addresses, potential needs, resources, referrals for other disciplines etc.
• Quality & Statistical Data -
  • Reviews medical record for abnormal findings,complications, delays and deviations from expected clinical outcomes reports such to Provider and/or Director to maintain an efficient, cost effective episode of care for each patient and documents intervention provided.
  • Maintains current working knowledge regarding regulatory requirements and insurance review procedures, forms, and portal updates.
  • Utilizes knowledge to redesign systems for improving performance.
  • Continuously prioritizes projects, activities, and tasks to ensure deadlines and customer needs are met.
  • Assists with preparation of reports/statistics as it pertains to staff specific workflow.
  • Reviews pre-admission screen forms for accuracy. Note any pre-authorized dates of service and insurance specific communication related to concurrent review/discharge notification.
  • Responsible for correcting issues with pre-auth to ensure reimbursement – including obtaining auth for patients who are admitted without proper auth in place.
  • Conduct daily comprehensive utilization reviews for inpatient psychiatric and substance use disorders to ensure compliance with medically necessary criteria.
  • Request administratively necessary days when a patient no longer meets criteria for inpatient level of care. Determine state involvement as reimbursement for DMH active clients differs from the standard Medicaid rate.
  • Participate in 72 hour meeting with patient/HCP/Family/Guardian,Social Worker, and Unit Leader to facilitate education regarding anticipated LOS and advance discharge planning inititation/expectations.
  • Attend collaborative meetings with insurers to review statistical trends, discuss complex cases, and review quality data reports
• Denials/Appeal Process -
  • Completes assessment of denial within 1 week providing supporting documentation with outcome of review; documents intervention in the UR EMR section.
  • Coordinates Medical Director and Peer to Peer reviews in accordance with insurance regulations.
  • Prepare written appeal letters, termination letters, discharge notices, MOON and IMs when appropriate as per regulatory standards and department policies.
  • Report any variances, trends to director. Submits denials/appeals when completed.
  • Collaborate with Director of Behavioral Health to address BH patient accounts where payment denial exists – work with denial mgmt team for resolution.
• Discharge Planning -
  • Communication: In collaboration with BH Social Worker builds rapport and responds to needs of physician, reviewers for managed care plans, healthcare team members, 3rd party payers, outside reviewers and vendors to enhance internal and external customer service satisfaction.
  • The Discharge Planning Process: Throughout patient admission collaborates with the BH Social Worker to provide assistance and guidance ongoing for discharge planning needs.
  • Maintain sufficient familiarity with inpatient behavioral health social work functions, including discharge planning, care coordination, community referrals, family/collateral communication, resource identification, and documentation requirements, to ensure continuity of patient care during periods of Social Worker absence or increased unit need.
  • Performs any and all other duties as assigned by director and/or designee.

Statement of Other Duties

This document describes the major duties and responsibilities for this job and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that employees may be asked to perform job-related duties beyond those explicitly described.

Functional Demands

Exerts 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Frequently reaches (extending hands and arms in any direction), handles (seizing, holding, grasping, turning, or working with hands), and feels (perceiving attributes of items such as size, shape, temperature, or texture by means of fingertips). Occasionally stoops (bending the body downward and forward by bending the spine at the waist), and kneels (bending the legs at knee to come to rest on knee or knees).

Qualifications

Job Requirements

Minimum Education

• BSN preferred.

Minimum Licenses/Certifications

• RN with current Massachusetts Registered Nurse License required.

Minimum Work Experience

• Previous UR/QA experience required.
• 2 years of healthcare experience within Behavioral Health and/or Insurance Industry required.

• Discharge Planning experience as it pertains to the care transitions, referral process, patient preference/choice; services, patient & family satisfaction; post discharge follow up etc.

Required Skills

• Proficient computer skills required.
• Must have effective written, verbal and interpersonal communication skills.
• Excellent critical thinking.
• Ability to multitask and flexibility essential.