UM Inpatient Clinical Review Nurse

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. LOCATION: This is a full-time remote opportunity. Current States Eligible MA and CT SCHEDULE: REQUIREMENTS: - 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...