UM Inpatient Clinical Review Nurse

Baystate Health • Springfield, MA

1d • Remote

About The Position

The UM Inpatient Clinical Review Nurse contributes to the overall success of the Utilization Management department by performing clinical reviews for inpatient, including determining the member’s overall health, reviewing the type of care being delivered, and evaluating medical necessity, in compliance with governing regulations, internal policies, and procedures.

Requirements

• Current MA RN License, required
• Bachelor's degree, required
• 3-5 years nursing experience
• Knowledge of utilization management, Medicare and Medicaid strongly preferred
• Highly developed critical thinking skills- prior nursing experience ICU or ER
• Computer literacy and ability to navigate through computer systems
• Excellent written and verbal communication skills, including delivering presentations
• Excellent time management skills with the ability to manage multiple priorities
• Ability to manage an assigned caseload independently
• Strong teamwork skills

Responsibilities

• Performs pre-service, concurrent, and retrospective reviews of members for appropriate care and setting to determine overall health and appropriate level of care, using applicable coverage documents and clinical guidelines
• Collects, documents, and maintains review findings and actions taken on member medical records in health management systems, according to utilization management policies and guidelines
• Works with healthcare providers to approve medical determinations or provide recommendations based on requested service and review findings
• Collaborates with Medical Directors, when determination to deny a request is indicated
• Assists with providing education to providers on utilization processes to ensure high quality, appropriate care to members
• Collaborates with care management on referral of members, as appropriate
• Performs clinical reviews for member and provider appeals related to inpatient services
• Participates in the weekend call program, as well as flexible work hours, as needed within the department
• Provides input to the Medical Policy Committee regarding the development/updating of medical policies

Benefits

• High-quality, low-cost medical, dental and vision insurance
• Generous PTO
• Continuing education support and reimbursement
• Wellbeing programs that include but are not limited to mental, physical, and financial health
• Pet, home, auto and personal insurance
• Life insurance
• Reimbursement for a variety of wellbeing activities, included but limited to gym membership and equipment, personal trainer, massage and so much more!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level