Clinical Reviewer, Inpatient RN

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Job Summary

The Clinical Reviewer, Inpatient RN, is a licensed professional that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of members across one or more types of inpatient settings; acute, subacute, acute rehabilitation, LTAC, CORF and others. 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 (Carelink/Cigna).

The Clinical Reviewer, Inpatient RN is expected to demonstrate the ability to work independently as well as collaboratively within a team environment. The Clinical Reviewer, Inpatient RN will be expected to demonstrate sound clinical and health plan business knowledge in their decision-making processes, on behalf of the health plan. A working understanding of departmental and corporate business objectives and accountability for outcome measures are critical to the Clinical Reviewer, Inpatient RN’s success in this role.

The Clinical Reviewer, Inpatient RN provides timely, clinically appropriate and cost-effective utilization management and discharge planning activities for THP members receiving services at her / his assigned facilities and may be required to float to provide coverage at unassigned facilities. Inpatient management II functions include but are not limited to; application of clinically relevant criteria sets in order 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 licensed clinical criteria sets (such as InterQual or MCG), THP 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 and/or assigned facilities contractual arrangements. Examples include but may not be limited to DRG (APR and MS), case rate and/or per diem reimbursement models.

The Clinical Reviewer, Inpatient RN works under the general direction of the Inpatient Team Manager or department Manager.

Key Responsibilities/Duties – what you will be doing

• Provide a range of utilization management 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, telephonically or by other electronic means for length of stay (LOS), medical necessity, discharge planning and care coordination requirements / needs.

• Identifies and determines medical necessity of out of network requests for services

• Performs discharge planning for both acute and post-acute admissions.

• Identifies complex members and refers member to case management or disease management program based on member specific diagnoses, circumstances or psychosocial needs, and product / LOB program requirements.

• May require telephonic and/or onsite presence at assigned facilities

• Redirects members and providers to in network or in network preferred providers, including transition back to the Tufts Health Plan service area.

• Identifies potential High Risk High Needs members and presents at case rounds for inclusion of additional interventions.

• Identifies potential high-cost members for reserve or re-insurance planning.

• 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 rounds

• Become subject matter expert (SME’s) to support the Inpatient Management Initiatives including but not limited to Progeny, OON Management, MedHok, Medical Trend Management, Cigna Self Insured accounts etc.  

• Assist the Team Manager in day-to-day activities/assignments to the team as needed.

• Develop effective and collaborative relationships with key customers:

• With clinical and business staff of assigned facilities and physicians providing direct care to THP members in order to: actively participate in the assessment of the member’s needs, matching the available in network provider and community services to those needs; recommend and facilitate adjustments to the care plan and services in place including the transition of OON admissions back into the network.

• With THP Medical Directors to determine ongoing coverage for inpatient services, including approved, denied and/or redirected services, ensuring that department business processes are followed or variances to the process are escalated, if needed, and agreed to and well documented

• With entities who support the UM function of the Carelink product, Cigna Travel

• With partner departments in / across THP to coordinate and expedite clinical and administrative processes as needed

• Prepare cases for presentation at and actively participate in weekly UM/CM Integrated Rounds.

• Participate 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

Compensation & Total Rewards Overview

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent.  We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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