ONSITE: MA (Near Boston) 

PAY:$40hr. 

HOURS:  Monday- Friday 8:30 am- 5:00 pm

FULL TIME:  6 MONTH + CONTRACT 

KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS (in order of importance and as applicable to assigned role) 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.
• Determines reimbursement methodology and schedules concurrent review appropriately
• Reviews inpatient admissions, 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
• Identifies complex members and refers member to case management or disease management program based on member specific diagnoses, circumstances or psycho social needs, and product / LOB program requirements.
• Redirects members and providers to in network or in network preferred providers, including transition back 
• 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
• 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 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. * 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.