Job description

Duration: 4 months contract (with possible extension)

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 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 Requirement: (Include interpersonal skills)

Excellent interpersonal skills to form positive and collaborative relationships.
Strong communication skills
Excellent negotiation skills
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

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.

*Note: Candidate needs to have an active Massachusetts RN license.

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

AI Statement: By applying, you acknowledge that AI-assisted tools may be used during hiring.

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Clinical Reviewer, Inpatient RN # 26-26518

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