Clinical Reviewer, Inpatient RN
P
Point32HealthHealthcare
United StatesFull-TimeMiddle
Salary94,472.97 - 141,709.45 USD per year
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Job Details
- Experience
- 3 years of clinical nursing experience; 3 years of Utilization Management experience.
- Required Skills
- Microsoft Excel
Requirements
- Registered nurse with current, unrestricted Massachusetts RN license.
- Associate degree (minimum); BSN preferred.
- 3 years of clinical nursing experience.
- 3 years of Utilization Management experience.
- Ability to apply evidence-based clinical criteria sets (such as InterQual or MNGs).
- Strong negotiation, communication, and interpersonal skills.
- Proficiency with Microsoft Word and Excel.
- Ability to use a laptop for accurate documentation and clinical data entry.
- Ability to multitask and work independently as a self-directed professional.
Responsibilities
- 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, continued stays, and medical necessity for discharge planning.
- Identify and determine medical necessity for out-of-network requests.
- Perform discharge planning for both acute and post-acute admissions.
- Redirect members and providers to in-network preferred providers.
- Prepare and present cases for weekly UM/CM Consultive Rounds.
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