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:
Utilization Review Nurse Background:
- 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.
- 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.