Utilization Management Review RN

1 week ago


Lynn, Massachusetts, United States Element Care Full time

The Utilization Management (UM) Review RN is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Utilization Management Review Nurse has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations. This position is full time Monday thru Friday 8am to 4pm with no weekend or holiday hours.

Essential Responsibilities:

  • Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to Medicare Part B medications, Long Term Services and Supports (LTSS), Home Health (HH) & surgical procedures.
  • Applies established criteria (e.g., InterQual, National Coverage Determination & Local Coverage Determination guidelines) and employs clinical expertise to interpret clinical criteria to determine medical necessity of services.
  • Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements.
  • Provides decision-making guidance to clinical teams on service planning as needed.
  • Works closely with RN Case managers & Medical Director to facilitate escalated reviews in accordance with Standard Operating Procedures.
  • Ensures accurate documentation of clinical decisions and works with Director of Clinical Case Management to ensure consistency in applying policy.
  • Works with Director of Clinical Case Management to ensure regulatory and contractual requirements are met.
  • Performs other duties as assigned.

Job Specification:

  • Registered Nurse currently licensed in the Commonwealth of MA
  • Bachelor of Science in Nursing degree preferred
  • 3 years of combined clinical and utilization management experience
  • 3 years of experience working in a health plan preferred
  • Covid vaccine required.

EEO Statement

Element Care is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, sexual orientation, protected veteran status, or on the basis of disability.

Element Care is committed to valuing diversity and contributing to an inclusive working environment.



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