Inpatient Utilization Management Clinician

About the role

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.

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, in a timely manner to meet 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.
• Sends appropriate system-generated letters to provider and member.
• Provides guidance and coaching to other utilization review nurses and participates in the orientation of newly hired utilization nurses.
• Participates in discussions with the facility discharge planning team to improve the progression of care to the most appropriate level of care.
• Identifies delays in care or services and manages with MD.
• Consults with the Medical Director, as needed, for complex cases.
• Follows all departmental policies and workflows in end-to-end management of cases.
• Participates in team meetings, education, discussions, and related activities.
• Maintains compliance with Federal, State and accreditation organizations.
• Identifies opportunities for improved communication or processes.
• May participate in audit activities and meetings.
• Documents rate negotiation accurately for proper claims adjudication.
• Identifies and refers potential cases to Care Management.
• Performs all other related duties as assigned.

Qualifications

• Active, unrestricted RN license in state of residence.
• Nursing degree or diploma required; bachelor’s degree in nursing preferred.
• RN license in state of MA, NH or compact license.
• Medicare and Medicaid knowledge.
• 2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines).
• Managed care experience.
• Experience performing discharge planning.

Licensure, Certification or Conditions of Employment

• Active, unrestricted RN license in state of residence.
• Pre-employment background check.
• Ability to take after-hours call, including evenings, nights, and weekends.

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.
• Demonstrated organizational and time management skills.
• Strong analytical and clinical problem-solving abilities with focus on quality improvement initiatives.

Working Conditions and Physical Effort

• Fully remote position with possible travel to the Charlestown, MA office for team meetings and training sessions.
• Fast-paced and dynamic work environment requiring adaptability and focus.
• Minimal physical effort required; primarily desk-based tasks such as documentation and virtual meetings.
• Regular and reliable attendance is essential.