Utilization Review Nurse #26-17499

Utilization Management Registered Nurse

Duration: 6 Month Contract (Possibility of Extension)

We are seeking an experienced Utilization Management (UM) Registered Nurse to support outpatient utilization review and prior authorization activities for a leading healthcare organization. The ideal candidate will have a strong background in managed care, utilization management, medical necessity review, prior authorization, and outpatient clinical review. This role is responsible for reviewing medical records, evaluating the medical necessity of requested services using established clinical guidelines, collaborating with physicians and healthcare providers, and ensuring timely authorization decisions while maintaining compliance with regulatory standards.

Key Responsibilities

• Perform outpatient utilization management (UM) and medical necessity reviews for prior authorization and precertification requests.
• Review clinical documentation and determine benefit eligibility using evidence-based clinical guidelines and health plan policies.
• Evaluate requests for outpatient procedures, surgeries, imaging, therapies, specialty medications, and other healthcare services.
• Ensure all utilization review activities meet regulatory turnaround time requirements.
• Collaborate with Medical Directors for complex cases, denial recommendations, and clinical escalations.
• Communicate authorization decisions with physicians, provider offices, hospitals, and healthcare facilities.
• Participate in appeal reviews and provide clinical recommendations when appropriate.
• Maintain accurate documentation within utilization management systems.
• Monitor cases for quality, compliance, and adherence to organizational policies.
• Identify opportunities for process improvement and contribute to quality initiatives.
• Serve as a clinical resource for internal teams regarding utilization management guidelines and medical necessity criteria.

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license.
• Associate Degree in Nursing (ADN) required.
• Minimum 5 years of RN clinical experience.
• Minimum 3-5 years of Utilization Management (UM), Case Management, Prior Authorization, or Medical Management experience.
• Previous Managed Care, Health Plan, Medicare, Medicaid, or Commercial Insurance experience.
• Strong knowledge of: Utilization Management (UM), Medical Necessity Review, Prior Authorization, Precertification, InterQual and/or MCG Guidelines.
• Experience reviewing outpatient clinical services.
• Excellent clinical assessment and critical thinking skills.
• Strong communication skills with providers and interdisciplinary teams.
• Ability to work independently in a remote environment.
• Comfortable using multiple systems while managing a high-volume workload.

Preferred Qualifications

• BSN preferred.
• Experience with outpatient utilization management.
• Experience using InterQual and/or MCG clinical criteria.
• Experience with Medicare Advantage or Commercial Health Plans.
• Previous experience with appeals, grievances, or denial reviews.
• Knowledge of NCQA, CMS, and utilization management regulatory requirements.

Note: Candidates can be remote but must have an active unrestricted Massachusetts RN License

About US Tech Solutions: US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.