Inpatient UM Clinician
Axelon
Summary:
- Location: Charlestown, MA
- Work Mode: Fully remote with possible travel to the Charlestown, MA office for team meetings and training sessions
- Perform utilization review activities, including concurrent and retrospective reviews of inpatient cases, applying evidence-based InterQual® criteria and Medical Policy.
- Obtain clinical information using facility EMR to assess and expedite timely decisions.
- Determine medical appropriateness of inpatient services following evaluation of medical and contractual guidelines.
- Utilize decision-making and critical-thinking skills in the review and determination of 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 not available.
- 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.
- 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.
- 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.
- Bachelor's degree in nursing.
- RN license in state of MA, NH, or compact license.
- Medicare and Medicaid knowledge.
- 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.
Vacancy posted 1 day ago
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