Job Description
- This is a W2/ Remote within a managed care setting requirement, but local candidates from MA are needed.
- Need independent candidates (USC/ GC) only.
We are seeking Utilization Review Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of post-acute care services, including inpatient rehabilitation, skilled nursing facility and long-term acute care levels of care. This role ensures alignment with evidence-based guidelines, regulatory requirements and organizational policies while promoting optimal patient outcomes and cost-effective care.
Key Responsibilities:
Conduct utilization review for post-acute care services, including: Inpatient Rehabilitation Facilities (IRF)/Acute Rehab, Skilled Nursing Facilities (SNF)/Subacute Nursing Facilities, and Long-Term Acute Care Hospitals (LTAC)
Review clinical documentation to determine medical necessity, level of care, and length of stay using approved criteria (e.g., InterQual and internal medical policies).
Perform: Prior authorization reviews, Concurrent reviews, and Retrospective reviews as needed.
Experience:
- 3–5 years of clinical nursing experience required
- Previous experience in a managed care organization required
- Prior experience in utilization review, case management, or discharge planning preferred
- Strong background in post-acute care settings (IRF, SNF, LTAC) highly desirable
- Familiarity with utilization review criteria (InterQual)
- Knowledge of post-acute levels of care and admission criteria