Inpatient UM Clinician

Description The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes. Responsibilities Performs utilization review activities, including concurrent, and retrospective reviews of inpatient cases applying evidenced-based InterQual® criteria and Medical Policy. Obtains clinical information using facility EMR, where accessible, to assess and expedite timely decisions. Determines medical appropriateness of inpatient services following evaluation of medical and contractual guidelines. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication. Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the Physician Reviewer time to make appropriate contact with the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT). Monitors inpatient cases for compliance with contractual obligations and regulatory requirements, ensuring timely reviews and authorizations. Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures. Sends appropriate system-generated letters to provider and member Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses Participates in discussions with the facility discharge planning team to improve the progression of care to the most appropriate level of care. Identify delays in care or services and manage with MD. Consults with the Medical Director, as needed, for complex cases. Follows all departmental policies and workflows in end-to-end management of cases. Participates in team meetings, education, discussions, and related activities Maintains compliance with Federal, State and accreditation organizations. Identifies opportunities for improved communication or processes May participate in audit activities and meetings Documents rate negotiation accurately for proper claims adjudication Identify and refer potential cases to Care Management Performs all other related duties as assigned Qualifications Active, unrestricted RN license in state of residence, Bachelor's degree RN license in state of MA, NH or compact license Medicare and Medicaid knowledge 2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines) Managed care experience Experience performing discharge planning Job Type & Location This is a Contract position based out of Boston, MA. Pay and Benefits The pay range for this position is $40.00 - $45.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave) Workplace Type This is a fully remote position.

Application Deadline This position is anticipated to close on Apr 20, 2026. Diversity, Equity & Inclusion At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I is embedded into our culture through: Hiring diverse talent Maintaining an inclusive environment through persistent self-reflection Building a culture of care, engagement, and recognition with clear outcomes Ensuring growth opportunities for our people Actalent is an equal opportunity employer. About Actalent Actalent is a global leader in engineering and sciences services. For more than 40 years, we've helped visionary companies advance their goals. Headquartered in the United States, our teams span 150 offices across North America, EMEA, and APAC—with four delivery centers in India led by 1,000+ extraordinary employees who connect their passion with purpose every day. Our Bangalore, Hyderabad, Pune, and Chennai delivery centers are hubs of engineering expertise, with core capabilities in mechanical and electrical engineering, systems and software, and manufacturing engineering. Our teams deliver work across multiple industries including transportation, consumer and industrial products, and life sciences. We serve more than 4,500 clients, including many Fortune 500 brands. Learn more about how we can work together at actalentservices.com.