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Clinical Reviewer, Inpatient RN
Point32Health. Provide utilization management activities for members in inpatient settings .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Management and clinical nursing, with a strong focus on applying Evidence Based Criteria and Medical Necessity Guidelines. Capable of mentoring staff, managing caseloads, and fostering collaborative relationships with healthcare providers.
Highest-signal resume keywords
Utilization Management ExperienceClinical Nursing ExperienceEvidence Based Criteria ApplicationRegistered Nurse LicenseMentoring Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ManagementClinical JudgmentMedical Necessity DeterminationDischarge PlanningCase DocumentationConcurrent ReviewPreauthorizationData EntryReimbursement MethodologyEvidence Based Criteria
Soft Skills
Effective CommunicationStrong NegotiationPeople SkillsMultitaskingTime Management
Tools & Technologies
MedHOKCase TrakkerJivaMicrosoft WordMicrosoft ExcelWeb/System-Based Communications Technology
Certifications & Qualifications
Registered Nurse LicenseAssociate DegreeBSN Preferred
Industry Keywords
Inpatient ManagementPost-Acute CareHigh Risk High Needs MembersConsultive RoundsCase Management
About the role
Key responsibilities & impact- Provide utilization management activities for members in inpatient settings
- Apply industry-standard and plan-proprietary criteria to determine appropriateness of inpatient and post-acute settings on initial and concurrent reviews
- Determine reimbursement methodology and schedule concurrent reviews
- Review inpatient admissions and continued stays for length of stay, medical necessity, and discharge planning
- Identify and determine medical necessity for out-of-network requests
- Perform discharge planning for acute and post-acute admissions
- Identify complex members and refer them to case management or disease management programs
- Redirect members and providers to in-network or preferred providers
- Identify potential High Risk High Needs members and present them at Consultive Rounds
- Conduct preauthorization of transplant requests as required
- Complete case documentation, daily tasks, UM event management, and same-day case data entry
- Mentor new and existing staff on process and system changes
- Facilitate UM/CM Consultive Rounds
- Serve as a subject matter expert supporting Inpatient Management initiatives and systems including MedHOK, Case Trakker, and Jiva
- Assist the Team Manager with day-to-day team activities and assignments
- Develop collaborative relationships with partner departments and key customers
- Prepare cases for and participate in weekly UM/CM Consultive Rounds
- Participate in committees or serve as team liaison as needed
- Maintain professional growth and development
- Perform additional related duties as assigned
Requirements
What you’ll need- Registered nurse with current, unrestricted Massachusetts RN license
- Associate degree required
- 3 years of clinical nursing experience
- 3 years of Utilization Management experience
- BSN preferred
- Strong people skills to form positive and collaborative relationships
- Effective communication skills
- Strong negotiation skills
- Ability to multitask and utilize clinical judgment to identify issues and escalate accordingly to a Manager
- Ability to apply Evidence Based Criteria and/or Point32Health Medical Necessity Guidelines to support utilization management
- Ability to mentor
- Ability to assume additional responsibilities such as special projects while managing a caseload; flexibility
- Ability to use a laptop to accurately document utilization management activities according to department documentation standards
- Ability to work independently with initiative, self-direction, and strong time management skills
- Proficiency with or ability to learn web/system-based communications technology
- Proficiency with or ability to learn Microsoft Word and Excel and other programs as needed
- Must be able to exercise sound judgment and make evidence-based clinical and business decisions
- Requires skill in responding to inquiries from providers
- Must be able to work under normal office conditions and work from home as required
- May be required to work additional hours beyond the standard work schedule
Benefits
Comp & perks- Variable pay eligibility
- Medical, dental and vision coverage
- Retirement plans
- Paid time off
- Employer-paid life and disability insurance with additional buy-up coverage options
- Tuition program
- Well-being benefits
- Full suite of benefits supporting career development, individual and family health, and financial health