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Utilization Review RN

Boston, MA · Healthcare
Utilization Review Nurse (RN) - Managed Care
Boston, MA (West Suburb, near Cambridge)

* Can start remotely due to COVID-19! *
** Full-Time, Benefits Available, CONTRACT position, expected to last several months, or longer! **

Utilization Review Nurse Job Summary:
  • The Utilization Review Nurse is responsible for utilization management and utilization review for prospective (prior authorization), concurrent, or retrospective review.
  • The Utilization Review Nurse will performs reviews of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
  • Utilize clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
  • The Utilization Review Nurse will obtain the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.
Utilization Review Nurse Background:
  • Current, valid, and unrestricted state Registered Nurse (R.N.) license.
  • Bachelor degree in nursing or related field preferred.
  • Certification in Coding (CPC/CCS/etc) or Utilization (CPUM/CPUR/CPHM) is a plus.
  • Requires Around 2-3 years acute care clinical nursing experience, to include working in high-acuity settings such as Med/Surg, ICU, Step-Down, ED/ER, OR.
  • At least 3 years of recent experience in Utilization Review / Utilization Management, additional years of Case Management or Quality Improvement are a plus. 
  • Atleast 1-2 years at a health plan or other Managed Care Organization (HMO/TPA/IPA/etc).
  • Requires experience using MCG/Milliman/InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
  • Computer skills to include Microsoft Word, Excel, database use, and basic data entry.


480.429.4005 (CALL – TEXT – FAX)
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