Position Title: Inpatient UM Clinician
Work Location: Remote
Duration: 3 months
Position Summary:

• The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes.

Key Responsibilities:

• Performs utilization review activities, including concurrent, and retrospective reviews of inpatient cases applying evidenced-based InterQual® criteria and Medical Policy.
• Obtains clinical information using facility EMR, where accessible, to assess and expedite timely decisions.
• Determines medical appropriateness of inpatient services following evaluation of medical and contractual guidelines.
• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication.
• Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available.
• Referrals must be made in a timely mbstanner, allowing the Physician Reviewer time to make appropriate contact with the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT).
• Monitors inpatient cases for compliance with contractual obligations and regulatory requirements, ensuring timely reviews and authorizations.
• Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures.
• Sends appropriate system-generated letters to provider and member
• Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
• Participates in discussions with the facility discharge planning team to improve the progression of care to the most appropriate level of care.
• Identify delays in care or services and manage with MD.
• Consults with the Medical Director, as needed, for complex cases.
• Follows all departmental policies and workflows in end-to-end management of cases.
• Participates in team meetings, education, discussions, and related activities
• Maintains compliance with Federal, State and accreditation organizations.
• Identifies opportunities for improved communication or processes
• May participate in audit activities and meetings
• Documents rate negotiation accurately for proper claims adjudication
• Identify and refer potential cases to Care Management
• Performs all other related duties as assigned

Qualification & Experience:

• Active, unrestricted RN license in state of residence.
• Education: Nursing degree or diploma required, bachelor’s degree in nursing
• Preferred/Desirable: Bachelor’s degree
• RN license in state of MA, NH or compact license
• Medicare and Medicaid knowledge
• Experience: 2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines)
• Managed care experience
• Experience performing discharge planning
• All employees working remotely will be required to adhere to the organization's Telecommuter Policy
• License: RpH (Mass or New Hampshire) depending on location of members

  
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 45.00/hr.