Job Description:
- 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.
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.
Qualifications:
- Active, unrestricted RN license in state of residence.
Education:
- Nursing degree or diploma required, bachelor’s degree in nursing
- 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’ Telecommuter Policy
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.
- Fully remote position with possible travel to the Charlestown, MA office for team meetings and training sessions
