[Hiring] Clinical Reviewer, Inpatient RN @USTech Solutions

Role Description

The Clinical Reviewer, Inpatient RN, is a licensed professional that is expected to function independently in her/his role and is responsible for managing a clinically complex caseload of members across one or more types of inpatient settings; acute, subacute, acute rehabilitation, LTAC, and others.

The Clinical Reviewer, Inpatient RN is responsible for:

• Making the determination of medical necessity and benefit coverage for multiple products/lines of business, such as Medicare or public plans.
• Demonstrating the ability to work independently as well as collaboratively within a team environment.
• Exhibiting sound clinical and health plan business knowledge in decision-making processes on behalf of the health plan.
• Providing timely, clinically appropriate, and cost-effective utilization management and discharge planning activities for members receiving services at assigned facilities.
• Floating to provide coverage at unassigned facilities as needed.
• Applying clinically relevant criteria sets to determine medical necessity, level of care, and/or readiness for transition to a lesser level of care setting.
• Developing effective working relationships with providers to facilitate the transition of the member through their continuum of care.
• Having direct experience with licensed clinical criteria sets (such as InterQual or MCG), proprietary Medical Necessity Guidelines, and product-specific payment policies.
• Managing multiple types of service reimbursement models, depending upon the line of business and/or assigned facilities contractual arrangements.

The Clinical Reviewer, Inpatient RN works under the general direction of the Inpatient Team Manager or department Manager.

Qualifications

• Registered Nurse with current, unrestricted MA license.
• BSN: Preferred.
• Minimum of three years of clinical nursing experience.
• Minimum of three years of UM experience, preferably in an inpatient setting or managed care environment.

Requirements

• Excellent interpersonal skills to form positive and collaborative relationships.
• Strong communication skills.
• Excellent negotiation skills.
• Ability to manage tasks to leverage non-clinical resources on the team.
• Use professional and clinical judgment to identify issues and escalate accordingly to a supervisor and relevant departments.
• Ability to apply nationally recognized standards to support utilization management.
• Ability to mentor.
• Ability to assume additional responsibilities such as special projects while managing a caseload.
• Ability to use a laptop to accurately document utilization management activities adhering to department documentation standards.
• Ability to work independently; highly motivated and self-directed with strong time management skills.
• Flexibility.
• Proficiency with or ability to learn technology for initiating and participating in web/system-based communications: webinar, instant messaging, thin client, soft phone, or others.
• Proficiency with or ability to learn technology-based programs such as Microsoft Word and Excel; other programs as needed.
• Fast-paced business environment that requires the balancing of multiple demands.
• Must be able to exercise sound judgment and make evidence-based clinical and business decisions.
• Requires skill in responding to inquiries from providers as well as telephonic inquiries from internal and external customers.
• Holiday/Weekend rotation may be required.
• *Note: Candidate needs to have an active Massachusetts RN license.

Company Description

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com .

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

By applying, you acknowledge that AI-assisted tools may be used during hiring.