Clinical Reviewer, Inpatient RN
Point32Health
full-time
Posted on:
Location Type: Remote
Location: Massachusetts • United States
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Salary
💰 $94,136 - $141,204 per year
About the role
- 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 schedules concurrent review appropriately
- Review inpatient admissions, continued stays, and discharge planning
- Identify complex members and refer members to case management or disease management programs based on member specific needs
Requirements
- Registered nurse with current, unrestricted Massachusetts RN license
- Associate degree or BSN preferred
- 3 years of clinical nursing experience
- 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 to identify issues and escalate accordingly to a Manager
- Ability to apply Evidence Based Criteria and/or P32H Medical Necessity Guidelines to support utilization management
- Ability to mentor and assume additional responsibilities such as special projects while managing a case load
- Proficiency with Microsoft Word and Excel; ability to learn technology for web/system-based communications
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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
Utilization ManagementClinical NursingEvidence Based CriteriaP32H Medical Necessity GuidelinesReimbursement MethodologyDischarge PlanningCase ManagementDisease Management
Soft Skills
People SkillsCommunication SkillsNegotiation SkillsMultitaskingClinical JudgmentMentoring
Certifications
Registered NurseMassachusetts RN License