Utilization Review Specialist - VNA

Berkshire Health Systems; Pittsfield (MA); On-site; USD 56,000 - 83,000; Full time

Benefits offered by this job

Health and dental insurance

Competitive retirement plan

Paid time off

Job summary

Berkshire Medical Center in Pittsfield, MA seeks an Utilization Program Specialist to evaluate the necessity and appropriateness of services, supporting case management and reimbursement aligned with BVNA standards. The role coordinates medical coding and supports clinical managers to ensure compliant, cost-efficient home health care.

Requirements include a minimum of 3 years in a certified home health agency, MA RN licensure, and Home Health coding certification.

Qualifications

• Minimum of 3 years of work experience in a certified home health agency.
• Knowledge of current regulations governing third party reimbursement for home health.
• Ability to cooperate, guide and instruct a multi-disciplinary team.
• Demonstrated ability to conform with Service Excellence Standards.

Responsibilities

• Evaluate necessity and appropriateness of services to ensure effectiveness and cost efficiency.
• Assist clinical staff with case management and ensure care is delivered per BVNA standards and regulatory requirements.
• Provide direction and act as a resource for Clinical Managers and staff regarding reimbursement.
• Translate medical information into medical codes according to home health coding conventions.

Skills

Time management

Multidisciplinary teamwork

Problem solving

Confidentiality

Education

BSN preferred

Home Health coding certification

Job description

Berkshire Medical Center · BMC VNA Utilization

Hourly Pay Range: 40.5400 through 60.2400

Monday - Friday

DEFINITION/PRIMARY FUNCTIONS

The Utilization Program Specialist is responsible for evaluating the necessity and appropriateness of services to ensure that they are effective and cost efficient. The Utilization Program Specialist works in tandem with the Clinical Manager to assist the clinical staff with case management and ensure care is delivered according to BVNA standards/pathways and regulatory requirements. He/she provides direction and acts as a resource for Clinical Managers and staff regarding reimbursement. The Utilization Program Specialist organizes, complies and translates medical information into medical codes according to home care coding conventions.

POSITION QUALIFICATIONS

Experience:

Minimum of 3 years of work experience in a certified home health agency. Experience with quality assurance or utilization review preferred.

Knowledge of current regulations governing third party reimbursement for home health required.

Ability to cooperate, guide and instruct a multi-disciplinary team required.

Ability to exercise independent judgement; demonstrated time management skills; demonstrated ability to facilitate smooth flow of home care patients.

Demonstrated ability to conform with Service Excellence Standards

Demonstrated knowledge of Conditions of Participation in home care.

Demonstrated general computer skills required. Demonstrated knowledge of Windows, including Microsoft Word, Excel and E-mail preferred.

Education and Training:

BSN nursing strongly preferred.

Certification in Current version of Home Health coding required.

License, Certification & Registration:

RN - Currently licensed as an RN in the state of Massachusetts

OACSHC - Certification in Outcome and Assessment Information Set (OASIS) as a COS-C- OASIS Specialist-Clinical or HCS-O- Home Care Clinical Specialist.

DRIVER - Driver's License

Other Requirements:

Ability to maintain confidentiality.

Ability to be flexible regarding work hours.

Knowledge of community resources.

Demonstrated problem-solving ability.

The minimum and maximum of the hourly pay range for this position is shown above. Actual rates of pay may vary based on a range of factors including but not limited to experience and qualifications. In addition to base pay, we offer a comprehensive benefits package that includes health and dental insurance, life and disability insurance, a competitive retirement plan contribution and a paid time off program.