Clinical Reviewer, Inpatient RN

🔥 17 hours ago

🇺🇸 United States – Remote

💵 $94.5k - $141.7k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

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Point32Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Point32Health is a leading nonprofit health and well-being organization that provides health coverage and services for individuals at all life stages. Through its family of companies, including Harvard Pilgrim Health Care and Tufts Health Plan, Point32Health offers a variety of health plans, programs, and services encompassing medical, pharmacy, wellness, and behavioral health. Point32Health is committed to health equity and has been recognized for its inclusive practices, earning distinctions in areas such as health equity, disability inclusion, and LGBTQ+ workplace inclusion. With a focus on innovative solutions and high-quality coverage, Point32Health strives to create a better healthcare experience for its members and communities.

📋 Description

• Provide utilization management activities for members in inpatient settings • Apply industry-standard and plan-proprietary criteria to determine appropriateness of inpatient and post-acute settings on initial and concurrent reviews • Determine reimbursement methodology and schedule concurrent reviews • Review inpatient admissions and continued stays for length of stay, medical necessity, and discharge planning • Identify and determine medical necessity for out-of-network requests • Perform discharge planning for acute and post-acute admissions • Identify complex members and refer them to case management or disease management programs • Redirect members and providers to in-network or preferred providers • Identify potential High Risk High Needs members and present them at Consultive Rounds • Conduct preauthorization of transplant requests as required • Complete case documentation, daily tasks, UM event management, and same-day case data entry • Mentor new and existing staff on process and system changes • Facilitate UM/CM Consultive Rounds • Serve as a subject matter expert supporting Inpatient Management initiatives and systems including MedHOK, Case Trakker, and Jiva • Assist the Team Manager with day-to-day team activities and assignments • Develop collaborative relationships with partner departments and key customers • Prepare cases for and participate in weekly UM/CM Consultive Rounds • Participate in committees or serve as team liaison as needed • Maintain professional growth and development • Perform additional related duties as assigned

🎯 Requirements

• Registered nurse with current, unrestricted Massachusetts RN license • Associate degree required • 3 years of clinical nursing experience • 3 years of Utilization Management experience • BSN preferred • Strong people skills to form positive and collaborative relationships • Effective communication skills • Strong negotiation skills • Ability to multitask and utilize clinical judgment to identify issues and escalate accordingly to a Manager • Ability to apply Evidence Based Criteria and/or Point32Health Medical Necessity Guidelines to support utilization management • Ability to mentor • Ability to assume additional responsibilities such as special projects while managing a caseload; flexibility • Ability to use a laptop to accurately document utilization management activities according to department documentation standards • Ability to work independently with initiative, self-direction, and strong time management skills • Proficiency with or ability to learn web/system-based communications technology • Proficiency with or ability to learn Microsoft Word and Excel and other programs as needed • Must be able to exercise sound judgment and make evidence-based clinical and business decisions • Requires skill in responding to inquiries from providers • Must be able to work under normal office conditions and work from home as required • May be required to work additional hours beyond the standard work schedule

🏖️ Benefits

• Variable pay eligibility • Medical, dental and vision coverage • Retirement plans • Paid time off • Employer-paid life and disability insurance with additional buy-up coverage options • Tuition program • Well-being benefits • Full suite of benefits supporting career development, individual and family health, and financial health