Massachusetts Licensed Utilization Clinician

Job Summary

To support optimal health outcomes, the full-time remote Massachusetts Licensed Utilization Clinician will evaluate inpatient medical treatments for necessity, monitor ongoing care, and facilitate discharge planning while collaborating with care management and medical directors.

Key responsibilities:

• Conduct utilization review activities, including concurrent and retrospective reviews of inpatient cases using evidence-based criteria
• Assess clinical information to expedite timely decisions regarding medical appropriateness of inpatient services
• Collaborate with discharge planning teams to enhance care progression and identify delays in services

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 discharge planning
• Knowledge of Medicare and Medicaid regulations