Remote Utilization Management RN | Impact Care Decisions

The Hollister Group; Massachusetts; Hybrid; USD 62,000 - 69,000; Full time

Job summary

The Hollister Group is seeking a Utilization Management RN to optimize patient care and ensure efficient use of healthcare resources. The role supports reviewing authorizations, evaluating medical necessity, and guiding quality care delivery in a remote or hybrid setting.

The ideal candidate holds a Massachusetts RN license, 2-4 years in utilization management, and experience with Medicaid, Medicare, and commercial lines. Proficiency with InterQual and healthcare software is preferred.

Qualifications

• Valid Registered Nurse license in Massachusetts.
• 2-4 years of experience in utilization management and managed care settings.
• Proven knowledge of Medicaid, Medicare, and commercial healthcare lines of business.
• Experience with InterQual or similar clinical review tools for inpatient, outpatient, and post-acute care.
• Bachelor's degree in Nursing or related healthcare field.
• Excellent communication skills, both written and verbal, with a professional approach.

Responsibilities

• Investigate prior authorization requests using clinical judgment to determine medical necessity and coverage, making approval decisions within your scope.
• Collaborate with physicians and healthcare providers to facilitate clinical review processes and clarify medical information.
• Stay informed on healthcare trends, managed care practices, and different lines of business including Medicaid, Medicare, and commercial products.
• Assess inpatient, outpatient, and post-acute services utilizing InterQual criteria to support care decisions.
• Maintain detailed documentation of decisions and communicate effectively across multiple channels.
• Utilize industry-standard tools and electronic health records to streamline review procedures and ensure accuracy.
• Demonstrate strong analytical skills to troubleshoot complex cases and develop well-informed solutions.

Skills

Communication

Teamwork

Education

Bachelor's degree in Nursing

Tools

InterQual

Microsoft Office

Job description

The Hollister Group is seeking a Utilization Management RN to optimize patient care and ensure efficient use of healthcare resources. The role supports reviewing authorizations, evaluating medical necessity, and guiding quality care delivery in a remote or hybrid setting.

The ideal candidate holds a Massachusetts RN license, 2-4 years in utilization management, and experience with Medicaid, Medicare, and commercial lines. Proficiency with InterQual and healthcare software is preferred.