Clinical Reviewer, Inpatient RN

US Tech Solutions; United States; On-site; USD 80,000 - 100,000; Full time

Job summary

A global staff augmentation firm is seeking a Clinical Reviewer, Inpatient RN, to manage complex inpatient caseloads and determine medical necessity. Candidates must possess a current Massachusetts RN license and have at least three years of clinical nursing and utilization management experience. Excellent interpersonal skills and the ability to work independently are essential. This role involves balancing multiple demands in a fast-paced business environment with potential holiday/weekend rotation requirements.

Qualifications

• Minimum of three years of clinical nursing experience.
• Minimum of three years of UM experience, preferably in an inpatient setting or managed care.

Responsibilities

• Function independently managing complex inpatient caseloads.
• Determine medical necessity for benefit coverage.
• Manage utilization and discharge planning activities.

Skills

Interpersonal skills

Time management

Clinical judgment

Mentoring

Proficiency in Microsoft Word

Proficiency in Microsoft Excel

Education

Registered Nurse with current, unrestricted MA license

BSN preferred

Job description

Duration: 4 months contract (with possible extension)

Note: Candidates needs to have a separate Massachusetts RN License.

Job 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, therefore, benefit coverage for multiple products / lines of business, such as Medicare or public plans.
• The Clinical Reviewer, Inpatient RN is expected to demonstrate the ability to work independently as well as collaboratively within a team environment. The Clinical Reviewer, Inpatient RN will be expected to demonstrate sound clinical and health plan business knowledge in their decision-making processes, on behalf of the health plan. A working understanding of departmental and corporate business objectives and accountability for outcome measures are critical to the Clinical Reviewer, Inpatient RN’s success in this role.
• The Clinical Reviewer, Inpatient RN provides timely, clinically appropriate and cost-effective utilization management and discharge planning activities for company’s members receiving services at her / his assigned facilities and may be required to float to provide coverage at unassigned facilities. Inpatient management functions include but are not limited to; application of clinically relevant criteria sets to determine medical necessity, level of care and/or readiness for transition to a lesser level of care setting. The Clinical Reviewer, Inpatient RN will develop effective working relationships with providers to facilitate the transition of the member through their continuum of care following department work processes and policies.
• The Clinical Reviewer, Inpatient RN will be expected to have direct experience with licensed clinical criteria sets (such as InterQual or MCG), proprietary Medical Necessity Guidelines and product specific payment policies. The Clinical Reviewer, Inpatient RN may have responsibility for multiple types of service reimbursement models, depending upon the line of business and/or assigned facilities contractual arrangements. Examples include but may not be limited to DRG (APR and MS), case rate and/or per diem reimbursement models.
• The Clinical Reviewer, Inpatient RN works under the general direction of the Inpatient Team Manager or department Manager.

Requirements

EDUCATION: (Minimum education & certifications required)

• Registered Nurse with current, unrestricted MA license
• BSN: Preferred

EXPERIENCE: (Years of experience)

• Minimum of three years of clinical nursing experience.
• Minimum 3 years of UM experience, preferably in an inpatient setting or managed care environment

SKILL REQUIREMENTS: (Include interpersonal skills)

• Excellent interpersonal skills to form positive and collaborative relationships.
• Ability to manage tasks to leverage non-clinical resources on team, provides quarterly audits of the non-clinical denial letter 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 case load
• 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

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)

• 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.

About US Tech Solutions

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, national origin, disability, or status as a protected veteran.