Tufts Medicine
RN System Director Utilization Management - Primarily Remote
Tufts Medicine, Burlington, Massachusetts, us, 01805
Overview
RN System Director Utilization Management - Primarily Remote. Full-time role at Tufts Medicine. Hours: Full-time, Monday through Friday. May require additional hours on weekends or off hours as needed. Location: Primarily remote, with occasional travel to local facilities including Tufts Medical Center, Melrose Wakefield Hospital, Lowell General Hospital, and our Corporate Headquarters in Burlington, MA. About Tufts Medicine: Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. The health system is the principal teaching affiliate for Tufts University School of Medicine. The strong relationship between Tufts Medicine and Tufts University School of Medicine is evident in our governance, academic and research structure. Responsibilities
Coordinate the design, development, implementation, and monitoring of the organization’s utilization review functions. Establish the department’s strategy and vision and oversee daily Utilization Management (UM) operations. Serve as the internal resource on issues related to resource utilization, care coordination across the continuum, and utilization review/management. Develop and lead the UM operations, strategy, and implementation of the UM model and tactics. Ensure success in financial management, human resources management, leadership, quality, and operational management objectives. Demonstrate Tufts Medicine core values and serve as a role model for other employees. Act as the UM first point of contact for Tufts Medicine. Address complex issues and root causes affecting metrics and targets. Lead the development of policies to decrease variation in UM practices. Coordinate UM metrics and tracking across markets; collaborate with utilization management, corporate and revenue cycle leaders; review metrics and discuss operational issues. Co-chair System UM Committee Meetings. Resolve issues related to performance according to process standards. Address human resources issues and facilitate participation in UM initiatives at corporate or local levels as approved by leadership. Ensure adequate staff with appropriate expertise to respond to inquiries about authorization numbers, days, admission status, and concurrent reviews. Oversee daily operations, leadership behaviors, and collaboration with Physician Advisors; attend system-based revenue cycle, finance, and operational meetings; collaborate with site Case Management leadership. Intervene in cases where admission or continued stay is unjustified or where there is disagreement on patient status between UM RN and attending physician. Collaborate with Clinical Documentation Integrity (CDI) and Coding leadership for data reviews and documentation improvement. In the absence of a Physician Advisor, consult the hospital Chief Medical Officer (CMO). Minimum Qualifications
Bachelor of Science in Nursing (BSN). Massachusetts RN Licensure. Current certification in case/utilization management (ACM, CCM, CMAC). Seven (7) years of UM/Case Management experience in an acute-care hospital or multi-hospital system, including two (2) years of supervisory experience. Preferred Qualifications
Master’s in Nursing. Fluent in CMS Two-Midnight, Inpatient-Only, Condition Codes 44 & W2, MOON/IMM, and payer-specific admission guidelines. Physical Requirements
Normal office settings. Skills & Abilities
Knowledge of InterQual and MCG medical-necessity criteria. Experience with Lean/Six Sigma or similar methodology to redesign and improve workflows. Proven ability to run multi-disciplinary projects. Confident presenter to executives, physician committees, and payer medical directors. Skilled at writing clear policies, job aids, and appeal letters. Ability to manage conflict between clinical teams and finance/revenue cycle priorities.
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RN System Director Utilization Management - Primarily Remote. Full-time role at Tufts Medicine. Hours: Full-time, Monday through Friday. May require additional hours on weekends or off hours as needed. Location: Primarily remote, with occasional travel to local facilities including Tufts Medical Center, Melrose Wakefield Hospital, Lowell General Hospital, and our Corporate Headquarters in Burlington, MA. About Tufts Medicine: Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. The health system is the principal teaching affiliate for Tufts University School of Medicine. The strong relationship between Tufts Medicine and Tufts University School of Medicine is evident in our governance, academic and research structure. Responsibilities
Coordinate the design, development, implementation, and monitoring of the organization’s utilization review functions. Establish the department’s strategy and vision and oversee daily Utilization Management (UM) operations. Serve as the internal resource on issues related to resource utilization, care coordination across the continuum, and utilization review/management. Develop and lead the UM operations, strategy, and implementation of the UM model and tactics. Ensure success in financial management, human resources management, leadership, quality, and operational management objectives. Demonstrate Tufts Medicine core values and serve as a role model for other employees. Act as the UM first point of contact for Tufts Medicine. Address complex issues and root causes affecting metrics and targets. Lead the development of policies to decrease variation in UM practices. Coordinate UM metrics and tracking across markets; collaborate with utilization management, corporate and revenue cycle leaders; review metrics and discuss operational issues. Co-chair System UM Committee Meetings. Resolve issues related to performance according to process standards. Address human resources issues and facilitate participation in UM initiatives at corporate or local levels as approved by leadership. Ensure adequate staff with appropriate expertise to respond to inquiries about authorization numbers, days, admission status, and concurrent reviews. Oversee daily operations, leadership behaviors, and collaboration with Physician Advisors; attend system-based revenue cycle, finance, and operational meetings; collaborate with site Case Management leadership. Intervene in cases where admission or continued stay is unjustified or where there is disagreement on patient status between UM RN and attending physician. Collaborate with Clinical Documentation Integrity (CDI) and Coding leadership for data reviews and documentation improvement. In the absence of a Physician Advisor, consult the hospital Chief Medical Officer (CMO). Minimum Qualifications
Bachelor of Science in Nursing (BSN). Massachusetts RN Licensure. Current certification in case/utilization management (ACM, CCM, CMAC). Seven (7) years of UM/Case Management experience in an acute-care hospital or multi-hospital system, including two (2) years of supervisory experience. Preferred Qualifications
Master’s in Nursing. Fluent in CMS Two-Midnight, Inpatient-Only, Condition Codes 44 & W2, MOON/IMM, and payer-specific admission guidelines. Physical Requirements
Normal office settings. Skills & Abilities
Knowledge of InterQual and MCG medical-necessity criteria. Experience with Lean/Six Sigma or similar methodology to redesign and improve workflows. Proven ability to run multi-disciplinary projects. Confident presenter to executives, physician committees, and payer medical directors. Skilled at writing clear policies, job aids, and appeal letters. Ability to manage conflict between clinical teams and finance/revenue cycle priorities.
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