Utilization Review Nurse

Location: Remote (Requires an active Massachusetts RN license (non-compact)) Employment Type: 4-month contract with possibility of extension Overview: We are seeking an experienced Inpatient RN Utilization Reviewer to independently manage a clinically complex inpatient caseload across multiple care settings, including acute, subacute, rehabilitation, and LTAC. This role is responsible for determining medical necessity and benefit coverage across multiple lines of business, including government-sponsored health plans. The ideal candidate is a self-directed clinical professional with strong utilization management experience, sound judgment, and the ability to balance clinical decision-making with health plan business objectives. Key Responsibilities: • Perform inpatient utilization management and discharge planning activities. • Apply nationally recognized clinical criteria (e.g., InterQual, MCG) to determine medical necessity, level of care, and readiness for transition. • Make timely, clinically appropriate, and cost-effective coverage determinations. • Manage a complex caseload independently while collaborating with internal clinical teams. • Communicate effectively with providers to facilitate care transitions across the continuum. • Apply product-specific payment and reimbursement models such as DRG, case rate, or per diem structures. • Identify issues requiring escalation and collaborate with leadership and cross-functional teams. • Maintain accurate documentation in accordance with departmental standards. • Participate in quality activities, audits, mentoring, and special projects as assigned. Requirements: Education & Licensure: • Registered Nurse with a current, unrestricted MA state license • BSN preferred Experience: • Minimum 3 years of clinical nursing experience • Minimum 3 years of utilization management experience (inpatient or managed care preferred) Skills & Competencies: • Strong clinical judgment and decision-making skills • Excellent communication, negotiation, and interpersonal skills • Ability to work independently in a fast-paced environment • Strong time management and organizational skills • Proficiency with or ability to learn UM systems and web-based communication tools • Working knowledge of Microsoft Word, Excel, and related applications • Flexibility to manage shifting priorities and caseloads Additional Notes: • Holiday and weekend rotation may be required • Role requires frequent interaction with providers and internal stakeholders 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 www.ustechsolutions.com . US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. Recruiter details: Name: Abdul Mannan Recruiter’s email id: [email protected] Job Diva ID: 26-02107