Massachusetts RN Utilization Reviewer

Job Summary

A company is looking for an RN Utilization Management Reviewer.

Key Responsibilities:

• Conducts timely clinical decision reviews for services requiring prior authorization across various clinical areas
• Applies established criteria and clinical expertise to determine medical necessity of services
• Communicates review results to the primary care team and ensures compliance with regulatory requirements

Required Qualifications:

• RN with an Associate's Degree required; Bachelor's Degree preferred
• Current RN license issued by the Massachusetts Board of Registration in Nursing
• 1 to 2 years of Utilization Management experience
• 2 or more years working in a clinical setting
• CCM (Certified Case Manager) certification is a plus