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Nurse Reviewer - RI more...
Location:Providence, RI
Company:Tufts Health Plan
First posted:November 04, 2016 (last updated 30+ days ago)

Job Description

The Nurse Reviewer is a licensed professional (Registered Nurse) 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 outpatient and inpatient (acute, subacute, acute rehabilitation, LTAC, and/or CORF) settings. The Nurse Reviewer ensures consistent and timely disposition of coverage decisions as required by product specific compliance and regulatory time frames. The Nurse Reviewer functions as a member of the Clinical Services team and works under the general direction of the Senior Inpatient Manager.

The Nurse Reviewer is responsible for making the determination of medical necessity and, therefore, benefits coverage for Rhode Island Together members. The Nurse Reviewer is expected to work collaboratively within a team environment. The Nurse Reviewer 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 Nurse Reviewer's success in this role.

The Nurse Reviewer provides timely, clinically appropriate and cost effective utilization management and discharge planning activities for members receiving services at her / his assigned facilities and may be required to float to provide coverage at unassigned facilities. The Nurse Reviewer functions include but are not limited to; application of clinical relevant criteria sets in order to determine medical necessity of inpatient and outpatient services, level of care and/or readiness for transition to a lesser level of care setting. The Nurse Reviewer 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 Nurse Reviewer will be expected to have direct experience with licensed clinical criteria sets (such as InterQual or THP proprietary Medical Necessary Guidelines (MNG's), and product specific payment policies. The Nurse 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.


Provide a range of utilization management activities for members in an inpatient and outpatient settings.


  • 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
  • Determines and schedules concurrent review appropriately
  • Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames.
    • 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.
    • 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 an onsite presence at assigned facilities
    • 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.


  • Utilize industry standard / plan proprietary criteria for determining the appropriateness of certain outpatient services and procedures.
  • Identifies and determines medical necessity of out of network requests for services
  • Redirects members and providers to in-network while adhering to Continuity of Care RI contract requirements.
  • Conducts preauthorization of transplant requests using applicable coverage documents, InterQual or Medically Necessary Criteria.
  • Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM processes.
  • Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.

Develop effective and collaborative relationships with key customers:

  • With clinical and business staff of assigned facilities and physicians providing direct care to Rhode Island Together 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
  • 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
  • Coaches letter writers to assure that appropriate medical necessity language is clearly defined in the denial letter.
  • Communicates frequently through the day with in network and non-network physicians, practices, facilities and/or allied health providers as appropriate.
  • Communicates frequently through the day with external customers (agents acting on behalf of the provider or member or both) regarding the rational for a determination, as well as the status and disposition of cases, as appropriate.
  • Orients new staff to role as needed.

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

Job Requirements


  • Registered Nurse with current, unrestricted MA and/or RI license
  • BSN: Preferred


  • Minimum of five years of clinical nursing experience of which a minimum of 3 years of UM experience, preferable in an inpatient setting or managed care environment.


  • Excellent interpersonal skills to form positive and collaborative relationships.
  • Strong communication skills
  • Excellent negotiation skills
  • Ability to manage tasks to leverage non-clinical resources on team
  • Use professional and clinical judgment to identify issues and escalate accordingly to a supervisor and relevant Tufts Health Plan departments
  • Ability to apply nationally recognized standards to support utilization management
  • Ability to use a laptop to accurately document utilization management activities adhering to department documentation standards
  • Ability to work independently; highly motivated and self--directed with strong time management skills
  • flexibility
  • Proficiency with or ability to learn technology for initiating and participating in web/system based communications: webinar, instant messaging, thin client, soft phone or others
  • Proficiency with or ability to learn technology based programs such as Microsoft Word and Excel; other programs as needed


  • 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 as well as telephonic inquiries from internal and external customers.


CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.


OFCCP Statement [OFCCP]
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability or protected veteran status.

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