Clinical Reviewer, Inpatient RN

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct utilization management activities for members within inpatient environments.

• Utilize both industry-standard and proprietary criteria to assess the suitability of inpatient and post-acute settings during initial and concurrent reviews.

• Establish reimbursement methods and schedule concurrent reviews accordingly.

• Evaluate inpatient admissions and ongoing stays for length of stay, medical necessity, and discharge planning.

• Identify and assess medical necessity for out-of-network requests.

• Manage discharge planning for both acute and post-acute admissions.

• Recognize complex members and refer them to case management or disease management programs.

• Guide members and providers towards in-network or preferred providers.

• Identify potential High Risk High Needs members and present them during Consultive Rounds.

• Conduct preauthorization for transplant requests as necessary.

• Complete case documentation, daily tasks, event management, and same-day data entry for utilization management.

• Mentor both new and existing staff on process and system updates.

• Facilitate UM/CM Consultive Rounds.

• Act as a subject matter expert in support of Inpatient Management initiatives and systems, including MedHOK, Case Trakker, and Jiva.

• Assist the Team Manager with daily team operations and assignments.

• Cultivate collaborative relationships with partner departments and key stakeholders.

• Prepare cases and engage in weekly UM/CM Consultive Rounds.

• Participate in committees or act as a team liaison when required.

• Commit to professional growth and development.

• Execute additional related duties as assigned.

⛳️ Requirements

• Must be a registered nurse with a current, unrestricted Massachusetts RN license.

• An associate degree is required.

• A minimum of 3 years of clinical nursing experience is needed.

• At least 3 years of experience in Utilization Management is required.

• A BSN is preferred.

• Excellent interpersonal skills to build positive and collaborative relationships.

• Strong communication abilities.

• Proficient negotiation skills.

• Capacity to multitask and apply clinical judgment to identify issues and escalate them to a Manager as necessary.

• Ability to implement Evidence-Based Criteria and/or Point32Health Medical Necessity Guidelines to support utilization management.

• Capability to mentor others.

• Willingness to take on additional responsibilities, such as special projects, while managing a caseload; flexibility is key.

• Proficient in using a laptop for accurate documentation of utilization management activities in accordance with departmental documentation standards.

• Capability to work independently with initiative, self-direction, and strong time management skills.

• Proficient with, or willing to learn, web/system-based communication technologies.

• Proficient with, or willing to learn, Microsoft Word and Excel, along with other necessary programs.

• Must demonstrate sound judgment and make evidence-based clinical and business decisions.

• Skilled in responding to inquiries from providers.

• Must be able to work under normal office conditions and work from home as required.

• May need to work additional hours beyond the standard work schedule.

🏝️ Benefits

• Eligibility for variable pay.

• Coverage for medical, dental, and vision.

• Retirement plans available.

• Paid time off.

• Employer-funded life and disability insurance with additional buy-up options.

• Tuition assistance program.

• Well-being benefits offered.

• Comprehensive benefits supporting career development, individual and family health, and financial well-being.