Inpatient UM Clinician in Boston, Massachusetts - #73187 | VanderHouwen

Description

Job Id: 73187

Inpatient UM Clinician
Our client is seeking an Inpatient UM Clinician to provide clinical review and oversight of inpatient services, helping ensure patients receive medically appropriate care at the right level and experience effective transitions following hospitalization. The ideal candidate is an experienced Registered Nurse with a strong utilization management background, sound clinical judgment, and the ability to independently manage complex cases in a fast-paced remote environment.

This role is fully remote with possible occasional travel to Boston, Massachusetts. Working Schedule will include working rotating Saturdays.

Inpatient UM Clinician Responsibilities

• Conduct concurrent and retrospective utilization reviews of inpatient cases to evaluate medical necessity and appropriate levels of care using InterQual and other evidence-based clinical guidelines.
• Review available clinical documentation, including electronic medical records, to make timely coverage and authorization determinations in accordance with clinical, contractual, and regulatory requirements.
• Monitor inpatient stays for progression of care, identify potential delays or barriers, and collaborate with physicians, care management, and facility discharge planning teams to support appropriate transitions of care.
• Escalate cases that do not meet established medical necessity criteria, lack applicable guidelines, or require additional clinical review to the appropriate physician or Medical Director within required turnaround times.
• Maintain thorough and accurate documentation of utilization review activities, determinations, communications, authorizations, and other case-related actions.
• Communicate effectively with providers, clinical teams, and internal stakeholders regarding case status, clinical information, and utilization management decisions.
• Identify patients who may benefit from additional care management services and facilitate appropriate referrals.
• Support compliance with applicable federal, state, contractual, and accreditation requirements throughout the utilization review process.
• Assist with onboarding, guidance, and coaching of utilization review nursing staff and participate in team education and knowledge-sharing activities.
• Contribute to audits, quality improvement efforts, and process enhancements that improve clinical review efficiency and patient outcomes.

Inpatient UM Clinician Qualifications

• Active, unrestricted Registered Nurse (RN) license in the candidate’s state of residence is required.
• Nursing degree or diploma is required; bachelor’s degree in nursing is preferred.
• 2+ years of utilization review/utilization management experience, including experience applying evidence-based criteria such as InterQual.
• Previous managed care experience and demonstrated knowledge of inpatient utilization management practices.
• Experience supporting discharge planning and transitions of care.
• Strong clinical judgment, critical-thinking, and problem-solving skills with the ability to assess complex inpatient cases and determine appropriate levels of care.
• Strong written and verbal communication skills with the ability to collaborate effectively with physicians, clinical teams, facilities, and other stakeholders.
• Ability to independently prioritize and manage a high-volume caseload while meeting established review timelines and regulatory requirements in a remote environment.
• Knowledge of Medicare and Medicaid requirements is preferred.
• RN licensure in Massachusetts, New Hampshire, or through a Nurse Licensure Compact state is preferred.
• Proficiency with Microsoft Office and electronic clinical, documentation, or data management systems.
• Ability to participate in a rotating Saturday schedule and provide after-hours coverage, including evenings, nights, or weekends, as required.
• Ability to work remotely with reliable attendance and travel occasionally for team meetings or training, as needed.

Compensation: $45-$50/hr. (DOE)

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As an eligible contract employee with VanderHouwen, you’ll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.

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