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.

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, 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.

Qualifications – what you need to perform the job.

Certification and Licensure

Registered nurse with current, unrestricted Massachusetts RN license

Education

Required (minimum): Associate degree
Preferred: BSN (Bachelor of Science in Nursing)

Experience (minimum years required):

Required (minimum): 3 years of clinical nursing experience; 3 years of Utilization Management experience.

Working Conditions and Additional Requirements

Fast-paced business environment that requires the balancing of multiple demands. Must be able to exercise sound judgment and make evidence based clinical and business decisions. Requires skill in responding to inquiries from providers. Must be able to work under normal office conditions and work from home as required. Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations. May be required to work additional hours beyond standard work schedule.

Salary Range

$94,472.97 - $141,709.45

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity.