At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission—from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.
At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare — people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds – to apply.
Job Summary
SummaryPerforms concurrent reviews of outpatient and in-patient claims and performs authorization reviews of patient services. Pursues receipt of high-quality medical outcomes for patients who require precertification/preauthorization.<br><br>Does this position require Patient Care? Essential Functions Assesses, reviews, and assigns cases for utilization review (UR)
-Assists with the negotiations of access to care in specified targeted areas; maintains relationships with providers who provide services to patients and pursues a responsive system for authorization of services and approved claims. <br>
-Assist with negotiating reimbursement rates with third party payers <br>
-Prepares clinical information for each concurrent review directly from the medical record.
-Protects healthcare organization value by keeping information confidential; cautioning others regarding potential breaches. <br>
-Facilitate effective communication between members of the treatment team
-Maintains compliance with regulation changes affecting utilization management
-Use appropriate screening criteria, knowledge and clinical judgment to assess patient needs. -Recognizes and reports appropriately cases of fraud, abuse or mis-utilization
-Ensure quality and quantity of documentation in medical records for UR.
Qualifications
Education Bachelor's Degree Related Field of Study required or Doctor of Physical Therapy Physical Therapy preferred Can this role accept experience in lieu of a degree? No Licenses and Credentials Licensed Clinical Social Worker [LCSW - State License] - Generic - HR Only preferred Social Worker [Licensed Independent Clinical Social Worker - LICSW - State License] - Generic - HR Only preferred Occupational Therapist [State License] - Generic - HR Only preferred Physical Therapist [State License] - Generic - HR Only preferred Registered Nurse [RN - State License] - Generic - HR Only preferred Licensed Mental Health Counselor [LMHC - State License] - Generic - HR Only preferred Experience clinical experience, including during training, working with Rehab, psychiatric in-patient population 2-3 years preferred Knowledge, Skills and Abilities - Broad knowledge of various insurances and government reimbursements. - Excellent analytical and management skills. - Strong written and oral communication skills. - Familiarity with the utilization review process preferred. - Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. - Broad knowledge of various insurances and government reimbursements is desirable. - Work independently, be self-directed and contribute as a member of a team.
Additional Job Details (if applicable)
Physical RequirementsStanding Frequently (34-66%) Walking Frequently (34-66%) Sitting Occasionally (3-33%) Lifting Frequently (34-66%) 35lbs+ (w/assisted device) Carrying Frequently (34-66%) 20lbs - 35lbs Pushing Occasionally (3-33%) Pulling Occasionally (3-33%) Climbing Rarely (Less than 2%) Balancing Frequently (34-66%) Stooping Occasionally (3-33%) Kneeling Occasionally (3-33%) Crouching Occasionally (3-33%) Crawling Rarely (Less than 2%) Reaching Frequently (34-66%) Gross Manipulation (Handling) Frequently (34-66%) Fine Manipulation (Fingering) Frequently (34-66%) Feeling Constantly (67-100%) Foot Use Rarely (Less than 2%) Vision - Far Constantly (67-100%) Vision - Near Constantly (67-100%) Talking Constantly (67-100%) Hearing Constantly (67-100%)
Remote Type
Remote
Work Location
115 Mill Street
Scheduled Weekly Hours
20
Employee Type
Regular
Work Shift
Day (United States of America)
EEO Statement:
The McLean Hospital Corporation is an Affirmative Action Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.