Utilization Review Nurse

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

Join Our Team as a Utilization Management RN – Make an Impact in Healthcare

Are you a dedicated Registered Nurse passionate about optimizing patient care and ensuring effective utilization of healthcare resources? Our client, a leading organization in the healthcare industry, is seeking talented Utilization Management RNs to join their dynamic team. This pivotal role offers an opportunity to leverage your clinical expertise and managed care experience to support meaningful health outcomes. Whether working remotely or in a flexible hybrid setting, you'll play a key role in reviewing authorization requests, evaluating medical necessity, and guiding quality care delivery.

Compensation

Hourly rate: $45-$50

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.

Requirements

• 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.
• Proficiency in Microsoft Office Suite, industry-specific applications, and healthcare software.
• Self-motivated with strong organizational skills to manage multiple priorities effectively.
• Ability to work independently in a remote or hybrid environment.

The Hollister Group is an equal opportunity employer. We welcome and encourage applications from people who are under-represented in their respective occupation or position.