RN Utilization Management Reviewer

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The Role
The Clinical Utilization Reviewer is responsible for facilitating care for members who may have complex healthcare needs, authorizing medically necessary services at the right level of care to promote optimal health.

This position is self-directed and works independently and collaboratively to facilitate care using clinical skills, principles of managed care, nationally-recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member’s benefit to provide the best quality care.

The Team
The Clinical Utilization Reviewer is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dieticians, pharmacist, clinicians, medical directors and more, who collaborate to facilitate care.

This position is eligible for our eWorker, Mobile, and Resident personas. This position can be fully remote, with the expectation to work in our Hingham office 1x month.

Key Responsibilities:

• Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service.

• Evaluate members’ clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care.

• Pass annual InterQual Interrater Reliability Test.

• Collaborate with a team of professionals, including clinical utilization managers, account representatives, member service associates, dietitians, and physicians, to provide members with a high level of care coordination.

• Interact with treatment providers, PCPs, physicians, therapists, and facilities needed to gather clinical information to support the plan of care.

• Support members on their family building journey by reviewing medical policies, benefits and authorization determinations.

• Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues.

• Understand member insurance products and benefits, as well as regulatory and NCQA requirements.

• Identify cases to be presented at medical rounds and follow up with providers on recommendations to achieve optimal outcomes for members.

• Support a positive workplace environment, collaborate, and share clinical knowledge and skills to support our culturally and demographically diverse member population.

• Other clinical duties as assigned.

Key Qualifications:

• Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team.

• Ability to assess, analyze, draw conclusions, and construct effective solutions.

• Excellent written and verbal communication skills.

• Proficient with multiple IT systems.

• Able to identify and set goals, follow processes, meet deadlines, and deliver expected outcomes with the appropriate sense of urgency.

• Ability to interpret, evaluate, and document complex medical information to identify and communicate relevant and actionable conditions, circumstances, and behaviors.

• Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.

• Willingness to learn new business and clinical skills.

Education and Experience:

• 3-5 years relevant experience in a variety of appropriate clinical health care settings (Inpatient, outpatient, or differing levels of care).

• Experience with IVF, maternity, reproductive and gender affirming health, preferred.

• 2-3 years of Utilization Management experience.

• Active licensure in Massachusetts is required, appropriate to position (RN)

• Licensure in additional states a plus.

• Note: Any restrictions against a license must be disclosed and reviewed.

• For Registered Nurses Only: A bachelor’s degree in nursing (BSN) is preferred.

#LI-Hybrid

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location

Hingham

Time Type

Full time

Hourly Range: $39.32 - $48.06

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting.  We may ultimately pay more or less than the posted range, and the