Job Description

UM Inpatient Clinical Review Nurse- Baystate Health, Health New England

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.

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

LOCATION:

This is a full-time remote opportunity. Current States Eligible MA and CT

SCHEDULE:

• Monday through Friday
• 6 weekends/ 1 holiday a year
• Flex schedule: 7:30-4:00pm, 8:00-4:30pm, 1 week a month working 8:30am-5:00pm

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

THE ADVANTAGES OF WORKING WITH BAYSTATE/HEALTH NEW ENGLAND!

• Competitive 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!

About Health New England

Based in Springfield, Massachusetts, part of Baystate Health, Health New England is a regional not-for-profit health plan serving over 160,000 members in central and western Massachusetts and parts of Connecticut. Health New England has been meeting the health care needs of its members for nearly 40 years. Health New England is committed to improving the health and lives of people of our community, both in our workplace and for our members. We are committed to creating opportunities for individuals of all backgrounds to grow and thrive.

Education:

Bachelors Degree (Required)

Certifications:

Compensation

Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.

Minimum - Midpoint - Maximum

$89,606.00 - $103,001.00 - $121,804.00

Equal Employment Opportunity Employer