RN Utilization Management Lead

Anna Jaques Hospital; Winchester (MA); On-site; USD 166,000 - 198,000; Full time

Job summary

Winchester Hospital is seeking a Utilization Management Specialist to oversee medical necessity surveillance, concurrent reviews, and patient status management. You will collaborate with finance to ensure appropriate reimbursement and contribute to discharge planning.

The role requires a BSN, 5+ years RN experience, and a CM certification within one year. A Master’s degree is preferred, with strong communication and interprofessional education skills to drive system-wide improvements.

Qualifications

• Bachelor's degree in Nursing is required.
• Master's degree in Nursing or related field is preferred.
• Five years of experience as a Registered Nurse is required.
• Five years of inpatient case management and utilization review experience are required.
• Certification in Case Management within one year of hire is required.

Responsibilities

• Perform medical necessity surveillance, concurrent clinical reviews, and patient status oversight.
• Coordinate with financial team to ensure proper reimbursement.
• Educate staff and present in formal and informal settings for compliance and performance improvement.
• Act as a liaison to improve documentation and workflow across departments.

Skills

Nursing clinical expertise

InterQual criteria

Education & staff training

Communication skills

English proficiency

Education

Bachelor of Science in Nursing

Master's degree in Nursing or related field

Tools

InterQual criteria system

Electronic Medical Records

Job description

Winchester Hospital is seeking a Utilization Management Specialist to oversee medical necessity surveillance, concurrent reviews, and patient status management. You will collaborate with finance to ensure appropriate reimbursement and contribute to discharge planning.

The role requires a BSN, 5+ years RN experience, and a CM certification within one year. A Master’s degree is preferred, with strong communication and interprofessional education skills to drive system-wide improvements.