Inpatient UM Clinician

Work Mode: Fully remote position

Responsibilities:

• Perform utilization review activities, including concurrent and retrospective reviews of inpatient cases using evidence-based InterQual® criteria and Medical Policy.
• Obtain clinical information from facility EMR to expedite timely decisions.
• Determine medical appropriateness of inpatient services following evaluation of medical and contractual guidelines.
• Utilize decision-making and critical-thinking skills in reviewing and determining coverage for medically necessary health care services.
• Review, document, and communicate all utilization review activities and outcomes.
• Refer cases to Physician Reviewer when treatment requests do not meet medical necessity per guidelines or when guidelines are unavailable.
• Monitor inpatient cases for compliance with contractual obligations and regulatory requirements, ensuring timely reviews and authorizations.
• Demonstrate strong interpersonal and communication skills when conducting reviews and interacting with physicians and staff.
• Send appropriate system-generated letters to providers and members.
• Provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses.
• Participate 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.
• Consult with the Medical Director, as needed, for complex cases.
• Follow all departmental policies and workflows in end-to-end management of cases.
• Participate in team meetings, education, discussions, and related activities.
• Maintain compliance with Federal, State, and accreditation organizations.
• Identify opportunities for improved communication or processes.
• May participate in audit activities and meetings.
• Document rate negotiation accurately for proper claims adjudication.
• Identify and refer potential cases to Care Management.
• Perform all other related duties as assigned.

Requirements:

• Active, unrestricted RN license in state of residence.
• Nursing degree or diploma required.
• Minimum 2 years of utilization review experience and evidence-based guidelines (InterQual Guidelines).
• Managed care experience.
• Experience performing discharge planning.
• Ability to take after-hours call, including evening/nights/weekends.

Preferred Skills:

• Bachelor’s degree in nursing.
• RN license in state of MA, NH, or compact license.
• Medicare and Medicaid knowledge.
• Strong oral and written communication skills.
• Strong clinical judgment 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 a focus on quality improvement initiatives.

Benefits:

• Regular and reliable attendance is essential.
• Fast-paced and dynamic work environment requiring adaptability and focus.
• Minimal physical effort required; primarily desk-based tasks such as documentation and virtual meetings.