Telecommute Utilization Review RN in Boston

Job Summary

A healthcare staffing and recruiting firm is in need of a Telecommute Utilization Review RN in Boston.

Must be able to:

• Perform utilization management and utilization review for prospective (prior authorization), concurrent, or retrospective review
• Perform reviews of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
• Utilize clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines

Qualifications Include:

• Current, valid, and unrestricted state Registered Nurse (R.N.) license
• Around 2-3 years acute care clinical nursing experience, to include working in high-acuity settings such as Med/Surg, ICU, Step-Down, ED/ER; or
• At least 3 years of recent experience in Utilization Review / Utilization Management, additional years of Case Management
• At least 1-2 years at a health plan or other Managed Care Organization (HMO/TPA/IPA/etc)
• Experience using InterQual criteria for medical necessity, setting and level of care, and concurrent patient management
• Ability to identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs