Who We Are Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health. Job Summary The Clinical Reviewer, Inpatient RN, is a licensed professional that is expected to function independently in his/her role and is responsible for managing clinically complex caseload of members for one or more lines of business for such as the inpatient settings; acute, subacute, acute rehabilitation, LTAC (Long-Term Acute Care). . The Clinical Reviewer, Inpatient RN is responsible for making the determination of medical necessity and, therefore, benefit coverage for multiple products / lines of business, such as Commercial (FI, SI, and exchange products), state specific Medicaid programs, or Federal programs or in and out of area. The Clinical Reviewer, Inpatient RN is expected to demonstrate the ability to work collaboratively within a team environment. The Clinical Reviewer, Inpatient RN will be expected to demonstrate clinical judgement and health plan business knowledge in their decision-making processes, on behalf of the health plan. A working understanding of departmental workflows, policies, and procedures, and understanding of the corporate business goals and objectives. Accountability for outcome measures is critical to the Clinical Reviewer, Inpatient RN’s success in this role. Provides timely, clinically appropriate, and cost-effective utilization management and discharge planning activities for Point32Health members receiving services at her / his assigned facilities and may be required to float to provide coverage at unassigned facilities. Inpatient management functions include but are not limited to; application of clinically relevant criteria sets to determine medical necessity, level of care and/or readiness for transition to a lesser level of care setting. The Clinical Reviewer, Inpatient RN will develop effective working relationships with providers to facilitate the transition of the member through their continuum of care following department work processes and policies. The Clinical Reviewer, Inpatient RN will be expected to have direct experience with evidence based clinical criteria sets (such as InterQual or MNGs), Point32Health proprietary Medical Necessity Guidelines and product specific payment policies. The Clinical Reviewer, Inpatient RN may have responsibility for multiple types of service reimbursement models, depending upon the LOB (Line of Business) and/or assigned facilities contractual arrangements. Examples include but may not be limited to DRG, and/or per diem reimbursement models. The Clinical Reviewer, Inpatient RN works under the general direction of the Inpatient Manager of the team/s and the Director of the Department. Job Description Key Responsibilities/Duties – what you will be doing (top five): • Provide a range of utilization management (UM) activities for members in an inpatient setting. • Utilize industry standard / plan proprietary criteria for determining the appropriateness of the inpatient setting on an initial and concurrent review basis, both acute and post-acute (as noted above). • Determines reimbursement methodology and schedules concurrent review appropriately. • Reviews inpatient admissions, continued stays, t by fax or other electronic means for length of stay (LOS), medical necessity, discharge planning. • identifies and determines medical necessity for out of network requests. • Performs discharge planning for both acute and post-acute admissions. • Identifies complex members and refers members to case management or disease management programs based on member specific diagnoses, circumstances or psychosocial needs, and product / LOB program requirements. • s • Redirects members and providers to in network or in network preferred providers, including transition back to the Point32Health Plans service area. • Identifies potential High Risk High Needs members and presents at Consultive Rounds for inclusion of additional interventions. • May be required to conducts preauthorization of transplant requests. • Performs case documentation according to Department standards including but not limited to timely completion of daily tasks, timely management of assigned UM events and same day case data entry. • Mentor new and existing staff in process and system changes/updates • Facilitate UM/CM (Consultive Rounds. • Become subject matter expert (SME’s) to support the Inpatient Management Initiatives MedHOK, Case Trakker, Jiva, • Assist the Team Manager in day-to-day activities/assignments to the team as needed. • Develop effective and collaborative relationships with key customers: • , • With partner departments in / across Point32Health to coordinate and expedite clinical and administrative processes as needed • Prepares cases for presentation at and actively participates in weekly UM/CM Consultive Rounds. • Participates in committees or as team liaison as needed. • Maintains professional growth and development through self-directed learning activities and/or involvement in professional, civic, and community organizations. • Performs additional related duties as assigned. Qualifications – what you need to perform the job. Certification and Licensure • Registered nurse with current, unrestricted Massachusetts RN license
