Utilization Management RN

About the role

Are you a dedicated Registered Nurse passionate about delivering quality patient care and navigating complex healthcare systems? Our client, a leading organization in healthcare insurance, is seeking experienced Utilization Management RNs to play a vital role in reviewing prior authorization requests, determining medical necessity, and ensuring efficient benefit coverage across diverse lines of business. This is an excellent opportunity to make an impact within a dynamic, remote environment where your expertise will support improved patient outcomes and streamline clinical operations.

Responsibilities

• Evaluate prior authorization requests through thorough medical necessity assessments and benefit coverage reviews.
• Make informed approval decisions within scope, identifying cases requiring physician review and completing determinations accordingly.
• Stay informed about healthcare trends and ensure compliance with evolving guidelines and policies.
• Collaborate effectively with healthcare providers, colleagues, and patients, maintaining professionalism and confidentiality.
• Leverage industry-specific tools such as InterQual® and familiar software platforms to enhance workflow and documentation.
• Demonstrate analytical thinking to identify strengths and weaknesses in healthcare solutions while managing multiple priorities efficiently.

Requirements

• Active Registered Nurse license in Massachusetts.
• Bachelor’s degree in Nursing or related healthcare field.
• 2-4 years of experience in Utilization Management and managed care environments.
• Familiarity with various lines of business, including Medicaid, Medicare, and Commercial products.
• Knowledge of InterQual® criteria in managed care patient settings.
• Strong communication skills, both verbal and written, with a focus on respectful dialogue.
• Technological proficiency with Microsoft Office Suite, SharePoint, industry-specific applications, and electronic health records.
• Self-motivated and highly organized with the ability to manage multiple tasks independently.

Pay

Compensation: $45.00-50.00/hour* Listed not guaranteed – potential offers vary based on experience level, qualifications, and internal equity and may be outside of this range. This is a remote contract position.