Utilization Review Nurse: Drive Evidence-Based Care & Resource Use

Boston Medical Center; Baltimore (MD); On-site; USD 68,000 - 110,000; Full time

Job summary

Boston Medical Center is seeking an experienced utilization management RN to support admitting teams in determining patient status and optimizing hospital resources. You will review clinical information using InterQual/MCG guidelines to ensure medical necessity, length of stay, and level of care, collaborating with physicians and payers.

The role requires a BSN or ASN (with BSN in progress), Maryland RN licensure, and 5 years acute care and 2 years utilization review/case management experience.

Qualifications

• Education: BSN OR ASN and currently enrolled in a BSN program with expected graduation within 3 years.
• Current Maryland RN license.
• Certification in Utilization Management/Care Management desired.
• Five (5) years diversified acute care experience; two (2) years Utilization Review/Case Management experience.

Responsibilities

• Reviews available EMR during pre-admission to determine appropriate patient status and classifcation.
• Reviews admission and continued stay criteria for defined patient group.
• Develops initial admission reviews and provides status recommendations to admitting providers.
• Coordinates with managed care and payers; ensures timely utilization compliance and authorizations.
• Participates with physicians and interdisciplinary teams on admission decisions, discharge planning, and documentation.

Skills

Critical thinking

Discharge planning

Oral and written communication

Analytical skills

Time management

Problem solving

Interdisciplinary collaboration

Physician interaction

Education

BSN

ASN

BSN in progress (3 years left)

Tools

InterQual

MCG criteria

Electronic Medical Records (EMR)

Job description

Boston Medical Center is seeking an experienced utilization management RN to support admitting teams in determining patient status and optimizing hospital resources. You will review clinical information using InterQual/MCG guidelines to ensure medical necessity, length of stay, and level of care, collaborating with physicians and payers.

The role requires a BSN or ASN (with BSN in progress), Maryland RN licensure, and 5 years acute care and 2 years utilization review/case management experience.