About Fallon Health:
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org.
The UM Nurse uses a multidisciplinary approach to organize, coordinate, monitor, evaluate and modify plans of care and/or service requests, focusing on selected complex medical and psychosocial needs of FH members and their families. The UM Nurse is responsible for assuring the receipt of high quality, cost efficient medical outcomes for enrollees. This role works with Medical Directors, Authorization Coordinators and Service Coordinators to perform first level review
to pre-certify elective services, procedures and tests utilizing established Care Coordination polices and protocols, Fallon Health benefit criteria, applicable regulatory review criteria and nationally accepted criteria for medical necessity determination.
Education: Graduate from an accredited school of nursing, or Bachelors (or advanced) degree in nursing
License: Active and unrestricted licensure as a Registered Nurse in Massachusetts.