Inpatient Utilization Management Clinician

WellSense Health Plan; United States; Remote; USD 74,000 - 108,000; Full time

Benefits offered by this job

Remote work

Competitive salary

Excellent benefits

Job summary

WellSense Health Plan in the United States is seeking an Inpatient Utilization Management Clinician to evaluate inpatient medical necessity, monitor treatment, and support discharge planning across care teams. This fully remote, full-time role requires an active RN license, nursing degree, and experience with InterQual guidelines and managed care.

You will collaborate with physicians and care management to ensure timely reviews, document outcomes, and maintain regulatory compliance.

Qualifications

• Active RN license in state of residence.
• Bachelor's degree in Nursing or diploma with licensure.
• Experience with InterQual guidelines and managed care is preferred.
• Ability to work remotely and manage after-hours responsibilities.

Responsibilities

• Performs utilization review activities using InterQual criteria and policy.
• Obtains clinical information from EMR to assess timely decisions.
• Determines medical necessity for inpatient services.
• Documents outcomes and communicates with providers and members.
• Refers cases to Physician Reviewer when needed in a timely manner.
• Supports discharge planning and progression of care with care teams.
• Maintains compliance with policies, regulatory requirements, and audits.

Skills

Oral and written communication

Clinical judgement

Interpersonal skills

Independent remote work

MS Office proficiency

Time management

Analytical problem-solving

Education

Bachelor's degree in Nursing

Tools

EMR systems

Job description

Job 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.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/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 manner, 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

Qualifications:

• 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 Wellenses' TelecommuterPolicy

Licensure, Certification or Conditions of Employment:

• Active, unrestricted RN license in state of residence
• Pre-employment background check
• Ability to take after hours call, including evening/nights/weekends

Competencies, Skills, and Attributes:

• Strong oral and. written communication skills.
• Strong clinical judgement and critical thinking skills to assess complex cases and determine appropriate levels of care.
• Excellent communication and interpersonal skills to engage effectively with internal and external stakeholders
• Ability to work independently in a remote environment while maintaining adherence to timeliness and regulatory requirements.
• Proficiency in Microsoft Office applications and data management systems.
• Demonstrated organizational and time management skills
• Strong analytical and clinical problem-solving abilities with focus on quality improvement initiatives

Working Conditions and Physical Effort:

• Fully remote position with possible travel to the Charlestown, MA office for team meetings and training sessions.
• Fast paced and dynamic work environment requiring adaptability and focus.
• Minimal physical effort required; primarily desk-based tasks such as documentation and virtual meetings.
• Regular and reliable attendance is essential.

Compensation Range

$35.58 - $51.68

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Note

This range is based on Boston-area data, and is subject to modification based on geographic location.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees