ER Utilization Review Nurse – InterQual Specialist

Boston Medical Center; United States; On-site; USD 68,000 - 110,000; Full time

Benefits offered by this job

Competitive salary

Free parking

Bus pass subsidy

Onsite fitness center

Tuition assistance

Health, dental, vision

401(a)/403(b) retirement

Job summary

GBMC HealthCare seeks an experienced Utilization Management RN to support admitting teams with patient status determinations and hospital resource utilization. The role uses InterQual/MCG criteria to assess medical necessity, LOS, and level of care, impacting payer notifications and patient outcomes.

The ideal candidate holds a BSN or ASN with BSN in progress, Maryland RN license, and 5 years of acute care experience including 2 years in utilization review/care management.

Qualifications

• BSN or ASN with BSN in progress and within 3 years of graduation.
• Maryland RN license required; Utilization Management and/or Care Management certification desirable.
• 5 years diversified acute care experience; 2 years UR/CM experience preferred.

Responsibilities

• Reviews available electronic medical records during pre-admission to determine patient status.
• Develops initial admission reviews and concurrent treatment plans per guidelines.
• Coordinates services with managed care and third-party payers.
• Ensures timely utilization reviews and clinical submissions to payers.
• Escalates complex cases to leadership and supports continuous improvement.

Skills

InterQual criteria

Utilization review

Discharge planning

Clinical knowledge

Communication

Problem solving

Time management

EMR review

Independent work

Analytical skills

Education

BSN

ASN with BSN in progress

Tools

InterQual software

EMR systems

Care management systems

Job description

GBMC HealthCare seeks an experienced Utilization Management RN to support admitting teams with patient status determinations and hospital resource utilization. The role uses InterQual/MCG criteria to assess medical necessity, LOS, and level of care, impacting payer notifications and patient outcomes.

The ideal candidate holds a BSN or ASN with BSN in progress, Maryland RN license, and 5 years of acute care experience including 2 years in utilization review/care management.