Massachusetts Licensed Utilization Clinician

Job Summary

A company is looking for an Inpatient Utilization Management Clinician responsible for evaluating inpatient medical treatments and ensuring optimal health outcomes for members.

Key Responsibilities:

• Perform utilization review activities for inpatient cases using evidence-based criteria
• Monitor inpatient cases for compliance with contractual obligations and regulatory requirements
• Collaborate with care management and medical directors to facilitate discharge planning and transitions of care

Required Qualifications, Training, and Education:

• Active, unrestricted RN license in the 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 experience performing discharge planning
• Knowledge of Medicare and Medicaid is desirable