Job Title: Inpatient UM Clinician
Location: 100% Remote (Possible travel to the Charlestown, MA office for team meetings and training sessions)
Duration: 2+ months (Possible extension)
Pay Rate: $42-$47/hour
Schedule: Regular Business Hours – Monday-Friday with Rotating Saturday Shift
Job Summary:

• 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.
• Monitors inpatient cases for compliance with contractual obligations and regulatory requirements, ensuring timely reviews and authorizations.
• Sends appropriate system-generated letters to provider and member.
• Participates 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.
• Consults with the Medical Director, as needed, for complex cases.
• Performs all other related duties as assigned.

Qualifications:

• Active, unrestricted RN license in state of MA, NH or compact license.
• Nursing degree or diploma required, bachelor’s degree in nursing preferred.
• Medicare and Medicaid knowledge preferred.
• 2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines)
• Managed care experience
• Experience performing discharge planning
• Pre-employment background check
• Ability to take after hours call, including evening/nights/weekends

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.