Clinical Utilization Specialist

2 weeks ago

Boston, Massachusetts, United States Atrium Staffing Full time
About Atrium

We're a people-centric organization that fosters an environment of collaboration, high performance, and innovation. Our team values your talents and celebrates your achievements.

Client Overview

Our client is a healthcare services organization dedicated to providing innovative health plans and care delivery programs. They're committed to serving individuals with the greatest healthcare needs, offering integrated and comprehensive services in multiple states. They coordinate with local staff, healthcare providers, and community entities to ensure person-centered care.

Job Overview

We're seeking a Utilization Review Nurse to join our team. As a Utilization Review Nurse, you'll play a pivotal role in evaluating the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities.

Responsibilities
  • Review patient medical records, diagnoses, treatments, and outcomes to ensure alignment with evidence-based guidelines and best practices.
  • Assess the appropriateness of medical services like tests, procedures, and medications.
  • Collaborate with Physicians, Therapists, and other healthcare providers to develop and implement care plans.
  • Provide recommendations and guidance based on clinical expertise and knowledge of medical policies and procedures.
  • Monitor patient progress, assess treatment effectiveness, and adjust care plans as needed.
  • Ensure compliance with healthcare regulations, including those related to medical necessity, quality assurance, and payer policies.
  • Manage healthcare costs by ensuring appropriate care and minimizing unnecessary procedures and treatments.
  • Facilitate communication and collaboration among healthcare teams for coordinated patient care.
  • Educate patients and families about their care and treatment options.
  • Advocate for patient needs and fair access to care, addressing barriers like financial constraints and insurance coverage limitations.
  • Participate in quality improvement initiatives to enhance care quality and patient safety.
  • Maintain accurate and thorough documentation of patient care for audits, research, and performance improvement.
Qualifications
  • Minimum of 3 years of combined clinical and utilization management experience.
  • Preference for experience working within a health plan.
  • Familiarity with a utilization management platform is preferred.
  • Ability to apply predetermined criteria (e.g., Medical Necessity Guidelines, InterQual) to service decision requests to assess medical necessity.
  • Flexibility and understanding of individualized care plans.
  • Ability to influence decision-making.
  • Strong collaboration and negotiation skills.
  • Strong interpersonal, verbal, and written communication skills.
  • Ability to work independently.
  • Comfort working in a team-based environment.
Education Requirements
  • Licensed Practical Nurse (LPN) with a valid certificate and active nursing license in good standing for the state relevant to the member's services.
  • Must have a Massachusetts nursing license RN Associate's degree or equivalent.
Benefits

Atrium Care Package available, upon eligibility (including healthcare plans, discount programs, and paid time off).

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