This page tracks remote clinician openings that are location-eligible for Washington.
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$35 - $75,000
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WellSense Health Plan is a nonprofit health insurance company. As an employer, the company strives to foster a fast-paced, goal-motivated, and supportive cultur
Role 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. Qualifications - Active, unrestricted RN license in state of residence. - Nursing degree or diploma required, bachelor’s degree in nursing preferred. - Bachelor’s degree. - RN license in state of MA, NH or compact license. - Medicare and Medicaid knowledge. Requirements - 2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines). - Managed care experience. - Experience performing discharge planning. - Active, unrestricted RN license in state of residence. - Pre-employment background check. - Ability to take after hours call, including evening/nights/weekends. Benefits - Full-time remote work. - Competitive salaries. - Excellent benefits. - Generous total compensation that includes benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing. Key Functions/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. - 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 participates 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. - Identifies delays in care or services and manages 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. - Identifies and refers potential cases to Care Management. - Performs all other related duties as assigned. Working Conditions and Physical Effort - Fully remote position with possible travel to the Charlestown, MA office for team meetings and training sessions. - Fast paced and dynamic work environment requiring adaptability and focus. - Minimal physical effort required; primarily desk-based tasks such as documentation and virtual meetings. - Regular and reliable attendance is essential. Compensation Range $35.58 - $51.68. This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness.
We are a not-for-profit offering Medicaid, Medicare Advantage, and Individual & Family health plans in Washington state.
• Perform utilization review for medical or behavioral health requests using utilization review criteria, technologies, and tools. • Identify, coordinate, and implement high quality, cost-effective alternatives when appropriate to the patient’s condition. • Support physician decision-making, working collaboratively with all members of the health care team, the patient, the patient’s family, co-workers, and internal and external customers to achieve optimal patient outcomes. • Ensure members have timely access to care and supports during transitions between levels of care. • Conduct review of hospital notification or prior authorization care requests against established clinical guidelines and health plan policies. • Conduct onsite visits to local facilities 1-3 times weekly to connect with members and support successful post-discharge transitions. • Collaborate with facilities to perform discharge planning. • Provide coordination support to members transitioning between care settings or returning home from a hospitalization. • Identify member needs and provide support to ensure necessary services are available during the transition period. • Collaborate with providers, office staff, and Care Coordination team to assure coordination of care in a timely manner according to contractual and regulatory timeframes. • Identify, coordinate, and ensure high quality care and appropriate care by focusing on supporting access to care and services across the continuum of care in accordance with the patient’s medical needs.
At GeneDx, we're driven by urgency and purpose: helping patients get diagnosed earlier. Our mission, to empower everyone to live their healthiest life through genomics, drives our team to make a tangible impact each day – and shapes our culture where high standards, strong teamwork, and meaningful ownership are the norm. We act with intention, support one another, and deliver work we're proud to put our names on. We bring energy, focus, and a bias for action. We push past the obvious, challenge assumptions, and make thoughtful, decisive calls. We stay curious, ask questions, and share direct feedback with respect.
• Serves as a point of contact for inbound clinician communications directed to the MSL team as needed. • Delivers proactive onboarding support for new ordering clinicians. • Tracks early ordering behavior and identifies opportunities for education, clarification, or escalation. • Responds to routine, noninterpretive questions related to test utilization, ordering workflows, and report navigation using approved resources; escalating nuanced or complex scientific discussions to the aligned MSL. • Triages requests for test result discussions and scientific consults to the appropriate MSL. • Prepares concise background summaries or context to support efficient hand-off of communication to the other MSLs as needed. • Supports follow-up clinician interaction after MSL engagements as appropriate. • Manages and organizes shared MSL inboxes, ensuring timely, professional, and accurate responses. • Documents clinician interactions, follow-ups, and escalations in designated tracking systems or CRM tools. • Collaborates closely with MSLs, Medical Affairs leadership, and cross-functional partners to ensure consistent, high-quality external engagement. • Contributes to the continuous improvement of MSL workflows, templates, and clinician support materials.
• Act as the main point of contact for clinicians, building trusted relationships and responding promptly to clinician needs while engaging internal resources as needed • Serve as the primary point of contact and coordinator for newly onboarding clinicians by managing internal requirements across departments and client needs • Host clinician welcome calls • Ensure clinicians are set up in internal systems • Coordinate with internal credentialing, licensing, and privileging (CLP) teams • Ensure clinicians are properly trained and educated on all systems and processes required to perform their work • Maintain critical clinician information including privileging profiles, work status, contract type, Pod assignment, demographics, and expiration tracking for CLP, EMR access, DEA/CDS, and other requirements • Maintain information needed to support clinicians while on shift, including EMR access and client-specific workflows • Proactively communicate upcoming changes such as new sites, workflows, announcements, and policies • Support clinicians with technical needs including EMR access, cart technology, and internal software while ensuring issue resolution • Monitor clinician compliance related to signed orders, consult notes, and required documentation • Distribute clinician dashboards, roadmaps, and reports as required • Organize and facilitate meetings, prepare meeting materials and minutes, and track action items • Support go-lives at new sites • Manage clinician offboarding processes • Perform other duties as assigned
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