Massachusetts Licensed Utilization Clinician

Job Summary

Evaluating inpatient medical treatments for necessity, the full-time remote Massachusetts Licensed Utilization Clinician will perform utilization reviews, facilitate discharge planning, and collaborate with care management to ensure optimal health outcomes for members.

Key responsibilities:

• Conducts utilization review activities, including concurrent and retrospective reviews of inpatient cases using evidence-based criteria
• Monitors inpatient cases for compliance with regulatory requirements and facilitates communication with care teams for discharge planning
• Documents and communicates all utilization review activities and outcomes, ensuring timely referrals to Physician Reviewers when necessary

Required qualifications:

• Active, unrestricted RN license in state of residence
• Nursing degree or diploma required; bachelor's degree in nursing preferred
• 2+ years of utilization review experience with evidence-based guidelines
• Managed care experience and familiarity with Medicare and Medicaid
• Ability to take after-hours calls, including evenings, nights, and weekends