Remote Utilization Management RN – Massachusetts

Job Overview

  • Clinical License RN
  • State(s) MA

Job details

Salary

$40 – $42 an hour

Job Type
Full-time
Contract

Full Job Description

Remote Utilization Review RN – Licensed in MA – Managed Care
Boston, MA* Fully Remote based in Massachusetts*
*Massachusetts license required*
** 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.
  • At least 3 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.
  • Billingual preferred

#CLINICAL
#CARE1

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