Remote Utilization Review Nurse | P2P & Denials Expert

Santa Barbara Cottage Hospital; United States; Remote; USD 59,000 - 142,000; Part time

Job summary

Mass General Brigham Incorporated is seeking a P2P Utilization Review Nurse to join the Central Utilization Management team. You will identify, prepare, and clinically review cases requiring payer peer-to-peer discussions, focusing on concurrent level-of-care denials and using InterQual/MCG criteria with thorough documentation.

You will collaborate with Physician Advisors, Emergency Department teams, Care Management, and UM colleagues to ensure accurate level-of-care determinations, support

Qualifications

• BSN required.
• RN license for Massachusetts.
• 5+ years clinical nursing experience in an acute care hospital.
• 3+ years utilization review, care management or utilization management experience.
• 1+ years applying InterQual and/or MCG criteria for level of care determination.
• 1+ years reviewing and managing payer denials, collaborating with physicians and interdisciplinary teams.
• Proficiency with EPIC and utilization management documentation workflows.

Responsibilities

• Apply nationally recognized criteria (InterQual/MCG) to evaluate payer denials and determine inpatient vs observation status.
• Perform detailed clinical record reviews to assess medical necessity, intensity of service, and severity of illness for peer-to-peer review and related processes.
• Document clinical rationale, level-of-care determinations, and recommendations in EPIC and tracking tools.
• Collaborate with Physician Advisors to prepare cases for peer-to-peer discussions and prep meetings.
• Serve as SME for utilization management, payer denial trends, and peer-to-peer workflows for internal stakeholders.
• Support reconsideration (CONI) processes and escalate complex cases to Physician Advisors as needed.
• Participate in quality improvement initiatives, denial trend analysis, and learning opportunities.
• Complete special assignments demonstrating expert-level knowledge of utilization review criteria.

Education

BSN

RN license (MA)

Clinical nursing

Clinical decision-making

InterQual/MCG criteria

Tools

EPIC

Job description

Mass General Brigham Incorporated is seeking a P2P Utilization Review Nurse to join the Central Utilization Management team. You will identify, prepare, and clinically review cases requiring payer peer-to-peer discussions, focusing on concurrent level-of-care denials and using InterQual/MCG criteria with thorough documentation.

You will collaborate with Physician Advisors, Emergency Department teams, Care Management, and UM colleagues to ensure accurate level-of-care determinations, support