LPN - Utilization Review Nurse

High Point & Affiliated Organizations; New Bedford (MA); On-site; USD 44,000 - 54,000; Full time

Benefits offered by this job

Health Insurance

Vision Insurance

Long & short term disability

401k/Retirement plan

Employee Assistance Program

CEU education days

Job summary

High Point & Affiliated Organizations is seeking a Universal RN for the Central Utilization Review Department in New Bedford, MA. The role emphasizes utilization management, insurance authorizations, and clinical reviews in substance use and mental health care.

Qualified candidates will have nursing, preferred master’s in social work/psychology, and experience with ASAM criteria and managed care. On-site position with full-time hours and comprehensive benefits in a supportive, mission-driven

Qualifications

• Requires nursing degree or equivalent; master’s preferred in social work/psychology/mental health with substance use/mental health experience.
• ASAM criteria knowledge and managed care experience are required.
• Proficient computer skills including Word, email, and EMR systems.

Responsibilities

• Submit licensure/certifications for position maintenance.
• Ensure compliance with Federal regs and HIPAA.
• Manage utilization review, authorizations, and insurance follow-up.
• Coordinate with treatment teams and providers for admissions and discharges.
• Assist with appeals and case documentation as needed.
• Attend mandatory meetings and trainings.
• Uphold patient rights and confidentiality.

Skills

ASAM criteria

Managed care

Customer service

Verbal & written communication

Team collaboration

Medical necessity

Ethics & boundaries

Problem solving

Critical thinking

Education

Nursing degree

Master's degree in social work/psychology/mental health

Tools

Microsoft Word

Email

Electronic Medical Records (EMR)

Microsoft Office

Job description

Program & Location: Central Utilization Review Department - New Bedford, MA
Qualifications: Graduate of an Accredited Professional School or Nursing or; master's degree in social work, clinical psychology/counseling or mental health preferred with experience in substance use and/or mental health services.
Pay Range: $32 - $39 per hour (experience, education & licensure dependent)
Status: Full Time, 40hrs/week
Shift: Monday-Friday 7:30am-4:00pm

On-Site in New Bedford, MA

About Us

High Point & Affiliated Organizations is a health and human service agency whose mission is to treat and prevent substance use disorders and mental illness. High Point has programs located throughout Southeast Massachusetts offering a full continuum of care for substance use and mental health treatment, including inpatient, outpatient, residential, and community-based services. Programs and services also assist survivors of abuse, violence, and families experiencing homelessness. High Point believes that everyone has inherent goodness, worth, and dignity. Our goal is to help individuals and families achieve personal change and improve their quality of life.

UR Nurse Requirements

• Proficiency with computers, Microsoft Word, email, typing, and other basic office technology.
• Knowledge of ASAM criteria;
• Managed care and utilization management experience;
• Able to organize and structure own workload, attention to detail, and ability to maintain up to date tracking and filing systems;
• Good clinical judgment, understanding of medical necessity and evidence-based practices;
• Understanding of boundaries and ethics;
• Possesses a pleasant telephone manner and customer service skills;
• Good verbal and written communication skills;
• The ability to work collaboratively with others in a collaborative and cooperative manner;
• Understands the diseases of psychiatry and addictions and treatment modalities;
• Presents professional at all times and allows for flexibility;
• Problem solving abilities;
• Critical thinking skills;
• TB screening;
• Certification in HPAO De-escalation training;
• Knowledge of computer programs including Microsoft Office and Electronic Medical Records.

UR Nurse Duties and Responsibilities:

• Maintains and submits any current Licensure or Certificate necessary for the performance of the position.
• Compliance with Federal Regulations, 42 CFR Part II, Confidentiality of Alcohol and Drug Abuse Patients and HIPPA
• Utilization management of all patients, ensuring proper authorization is obtained for all insured inpatient services;
• Clinical reviews with insurance companies for continued stay, step downs to lower level of care and step ups to higher level of care (except IPU);
• Responsible for assuring that the business office receives accurate billing information in a timely manner;
• Keep counselors / nurses of insured patients updated as to their status;
• Attend daily multi-disciplinary treatment team meetings;
• Obtain necessary clinical, medical, and treatment information from clinical and medical staff to provide a comprehensive concurrent review;
• Review all new admissions daily, verifying insurance eligibility, level of care, and obtaining all applicable authorizations;
• Complete, discharge summary information to insurance companies when applicable;
• Assist with admission approvals as needed;
• Attend mandatory meetings and trainings;
• Attend monthly departmental meetings;
• Responsible for continued education in the field of substance abuse, nursingandrelatedcourses, when necessary;
• Coordinate and support the initiation and completion of all appeal processes as necessary for insurance claim denials and/or retrospective reviews;
• Provide assistance and support on the unit when necessary;
• Utilizes standard precautions at all times;
• Demonstrates behaviors that recognize the rights of patients as defined by the patient rights;
• Other duties as assigned by the supervisor.
• Medical Insurance
• Vision Insurance
• Long & short term disability
• Discounted auto/home and renters insurance
• 403b - Retirement
• FSA & DSA
• PMLA
• Employee Assistance Program
• Eligibility for free classes to become a Licensed Counselor or Recovery Coach
• Education days to use towards CEU's
• Free meals at select programs and when available
• Unmatched Leave Time (FT employees can earn up to 3 weeks in first year)

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.