RN Utilization Management Reviewer

3-5 years relevant experience in clinical health care settings. Utilization Management experience preferred. Active licensure in Massachusetts required. BSN preferred for registered nurses. Self-directed, independent, adaptive, and collaborative. Ability to assess, analyze, draw conclusions, and construct effective solutions. Excellent written and verbal communication skills. Proficient with multiple IT systems. Ability to identify and set goals, follow processes, and meet deadlines. Ability to interpret, evaluate, and document complex medical information. Awareness, attitude, knowledge, and skills to work effectively with a diverse population. Willingness to learn new business and clinical skills.

Conduct pre-certification, concurrent, and retrospective reviews. Evaluate members’ clinical status, benefits, and appropriateness for programs and sites of service. Pass annual InterQual Interrater Reliability Test. Collaborate with a team of professionals to provide care coordination. Interact with treatment providers to gather clinical information. Monitor clinical quality concerns and escalate issues. Understand member insurance products and benefits. Identify cases for medical rounds and follow up on recommendations. Support a positive workplace environment and share clinical knowledge.