[Hiring] Clinical Reviewer, Inpatient RN @Point32Health

Role Description

The Clinical Reviewer, Inpatient RN, is a licensed professional responsible for managing clinically complex caseloads of members in inpatient settings, including acute, subacute, acute rehabilitation, and LTAC (Long-Term Acute Care). Key responsibilities include:

• Provide a range of utilization management (UM) activities for members in an inpatient setting.
• Utilize industry standard/plan proprietary criteria for determining the appropriateness of the inpatient setting on an initial and concurrent review basis.
• Determine reimbursement methodology and schedule concurrent reviews appropriately.
• Review inpatient admissions and continued stays for length of stay (LOS), medical necessity, and discharge planning.
• Identify and determine medical necessity for out-of-network requests.
• Perform discharge planning for both 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 at Consultive Rounds.
• Conduct preauthorization of transplant requests when required.
• Document cases according to Department standards, including timely completion of daily tasks.
• Mentor new and existing staff in process and system changes/updates.
• Facilitate UM/CM Consultive Rounds.
• Become a subject matter expert (SME) to support Inpatient Management Initiatives.
• Assist the Team Manager in day-to-day activities/assignments as needed.
• Develop effective and collaborative relationships with key customers and partner departments.
• Prepare cases for presentation at and actively participate in weekly UM/CM Consultive Rounds.
• Participate in committees or as team liaison as needed.
• Maintain professional growth and development through self-directed learning activities.
• Perform additional related duties as assigned.

Qualifications

• Registered nurse with current, unrestricted Massachusetts RN license.
• Education:
  • Required: Associate degree.
  • Preferred: BSN (Bachelor of Science in Nursing).
• Experience:
  • Required: 3 years of clinical nursing experience.
  • Required: 3 years of Utilization Management experience.
• Strong people skills to form positive and collaborative relationships.
• Effective communication skills.
• Strong negotiation skills.
• Ability to multitask and utilize clinical judgment.
• Ability to apply Evidence Based Criteria and/or P32H Medical Necessity Guidelines.
• Ability to mentor.
• Ability to assume additional responsibilities while managing a case load.
• Proficiency with technology for documentation and communication.

Requirements

• Fast-paced business environment requiring balancing of multiple demands.
• Ability to exercise sound judgment and make evidence-based clinical and business decisions.
• Must be able to work under normal office conditions and work from home as required.
• May require simultaneous use of a telephone/headset and PC/keyboard.
• May be required to work additional hours beyond standard work schedule.

Benefits

• 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 to support career development, individual & family health, and financial health.