RN Utilization Management Reviewer

1 week ago


Boston, Massachusetts, United States Commonwealth Care Alliance Full time
Job Summary

Commonwealth Care Alliance is seeking a skilled RN Utilization Management Reviewer to join our team. As a key member of our Clinical Effectiveness Unit, you will play a critical role in ensuring the medical necessity and appropriateness of healthcare services and procedures.

Responsibilities
  • Conduct timely clinical decision reviews for services requiring prior authorization in various clinical areas, including surgical procedures, Medicare Part B medications, Long Term Services and Supports (LTSS), and Home Health (HH).
  • Apply established criteria (e.g., InterQual and other available guidelines) and employ clinical expertise to interpret clinical criteria to determine medical necessity of services.
  • Communicate 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.
  • Provide decision-making guidance to clinical teams on service planning as needed.
  • Work closely with CCA Clinicians, Medical Staff, and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures.
  • Ensure accurate documentation of clinical decisions and work with UM Manager to ensure consistency in applying policy.
  • Work with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures, as well as regulatory and contractual requirements, are met.
Requirements
  • Associate's Degree.
  • 2 years of Utilization Management experience.
  • 2 or more years working in a clinical setting.
  • RN licensure.
  • Ability to complete assigned work in a timely and accurate manner.
  • Knowledge of the Utilization management process.
  • Ability to work independently.
  • English language proficiency.


  • Boston, Massachusetts, United States Commonwealth Care Alliance Full time

    About the RoleWe are seeking a skilled RN Utilization Management Reviewer to join our team at Commonwealth Care Alliance. As a key member of our Clinical Effectiveness Unit, you will play a critical role in ensuring the medical necessity and appropriateness of healthcare services and procedures.Key ResponsibilitiesConduct timely clinical decision reviews for...

  • RN Care Coordinator

    2 weeks ago


    Boston, Massachusetts, United States RN-Staff Full time

    Job SummaryWe are seeking a skilled RN Care Coordinator to join our team at RN-Staff. As a key member of our Case Management Department, you will play a vital role in ensuring seamless transitions of care for our patients.ResponsibilitiesUtilization Review: Conduct thorough reviews of patient records to determine medical necessity and appropriateness of...

  • Loan Review Manager

    6 days ago


    Boston, Massachusetts, United States Crowe Full time

    Job Description:The Loan Review Manager role at Crowe provides leadership to our people and clients to deliver loan review and credit consulting services, including outsourced and co-sourced loan review, staff augmentation, credit consulting, and credit remediation.Key Responsibilities:Provide leadership to loan review teams and clients to deliver...


  • Boston, Massachusetts, United States Atrium Staffing Full time

    About AtriumWe're a people-centric organization that fosters an environment of collaboration, high performance, and innovation. Our team values your talents and celebrates your achievements.Client OverviewOur client is a healthcare services organization dedicated to providing innovative health plans and care delivery programs. They're committed to serving...


  • Boston, Massachusetts, United States Commonwealth Care Alliance Full time

    Job SummaryWe are seeking a highly skilled and experienced Director of Utilization Management to lead our healthcare operations team. As a key member of our leadership team, you will be responsible for developing and implementing strategies to improve the quality and efficiency of our utilization management processes.Key ResponsibilitiesDevelop and implement...


  • Boston, Massachusetts, United States RN-Staff Full time

    Job Title: MA-PT-Fitchburg RN StaffWe are seeking a skilled and dedicated RN Staff to join our team at RN-Staff.Job SummaryThe successful candidate will be responsible for ensuring that all necessary documents are completed and attached to the candidate's submission, including a prescreen form, resume, and license verification. New graduates are welcome to...


  • Boston, Massachusetts, United States HNTB Full time

    About the RoleWe are seeking a highly skilled Stormwater and Utility Engineer III to join our team at HNTB. As a key member of our engineering team, you will be responsible for leading the design and development of stormwater management and utility projects.Key ResponsibilitiesDirect the design of effective and sustainable stormwater management...


  • Boston, Massachusetts, United States HNTB Full time

    About the RoleWe are seeking a highly skilled Stormwater and Utility Engineer III to join our team at HNTB. As a key member of our engineering team, you will play a critical role in leading the design and development of stormwater management and utility projects.Key ResponsibilitiesLead the design and development of stormwater management and utility...


  • Boston, Massachusetts, United States HNTB Companies Full time

    About the RoleWe are seeking a highly skilled and experienced Technical Lead to join our Stormwater and Utilities team at HNTB Companies. As a Technical Lead, you will be responsible for managing assigned projects throughout their full lifecycle, including developing scope and technical sections of proposal and procurement documents, participating in...


  • Boston, Massachusetts, United States City Facilities Management Ltd Full time

    Job SummaryWe are seeking a highly skilled Energy Management Systems Engineer to join our team at City Building Engineering Services (CBES). As a key member of our team, you will be responsible for reviewing, designing, and coordinating the energy management systems and electrical scope requirements for new and remodeled stores.Key ResponsibilitiesUtilize...


  • Boston, Massachusetts, United States City Facilities Management Ltd Full time

    Job SummaryWe are seeking a highly skilled Energy Management Systems Engineer to join our team at City Building Engineering Services (CBES). As a key member of our engineering team, you will be responsible for reviewing, designing, and coordinating the energy management systems and electrical scope requirements for new and remodeled stores.Key...


  • Boston, Massachusetts, United States InsideHigherEd Full time

    Job SummaryThe Deputy Director of Utilities oversees the day-to-day operations, maintenance, and engineering support of the Utility Plant and energy distribution across the campus. This role involves supervising Utility Plant Operators, ensuring safe and reliable delivery of utilities, and providing guidance for skill enhancement and success among the...


  • Boston, Massachusetts, United States RN-Staff Full time

    Job SummaryWe are seeking a highly skilled and compassionate Registered Nurse to join our Emergency Department team at RN-Staff. As a key member of our healthcare team, you will provide exceptional patient care, working collaboratively with physicians and other healthcare professionals to deliver high-quality patient outcomes.Key ResponsibilitiesAssess and...

  • Medical Director

    3 weeks ago


    Boston, Massachusetts, United States RN-Staff Full time

    About the RoleWe are seeking a highly skilled and dedicated Medical Director to join our team at the Greater Lawrence Family Health Center, Inc. (GLFHC). As a leading provider of community medicine, we are committed to delivering exceptional patient care to our diverse population.Key ResponsibilitiesProvide comprehensive and continuing care to patients...


  • Boston, Massachusetts, United States Vertex Full time

    Job Summary:The Director, Strategic Operations and Portfolio Review will play a key role in driving business value for Vertex through the discovery and development of novel medicines and therapies for serious diseases. As a member of the Data and Computational Sciences (DCS) department, you will influence the strategic direction for DCS, including the...


  • Boston, Massachusetts, United States HNTB Full time

    About the OpportunityWe are seeking a highly motivated and detail-oriented Civil Engineer Intern to join our Stormwater and Utilities Design team in Boston, Massachusetts. As a co-op in our team, you will have the opportunity to contribute to the design and development of stormwater management and utility projects.Key ResponsibilitiesAssist in the design and...


  • Boston, Massachusetts, United States RN-Staff Full time

    Job SummaryWe are seeking a highly skilled and dedicated Internal Medicine and Geriatrics Physician to join our team at the Greater Lawrence Family Health Center, Inc. (GLFHC). As a key member of our healthcare team, you will provide high-quality patient care to a diverse population in the Merrimack Valley.Key ResponsibilitiesProvide comprehensive and...


  • Boston, Massachusetts, United States RN-Staff Full time

    Job SummaryWe are seeking a highly skilled and compassionate Registered Nurse to join our Emergency Department team at RN-Staff. As a key member of our healthcare team, you will provide exceptional patient care, working collaboratively with physicians and other healthcare professionals to deliver high-quality patient outcomes.Key ResponsibilitiesAssess and...


  • Boston, Massachusetts, United States HNTB Full time

    About the RoleWe are seeking a highly motivated and detail-oriented Co-Op Civil Engineer to join our Stormwater and Utilities Design group in Boston, Massachusetts. As a Co-Op, you will have the opportunity to contribute to the design and development of stormwater management and utility projects, working closely with experienced design engineers to create...


  • Boston, Massachusetts, United States Cynet Health Full time

    Job Title: Travel Nurse RN Case ManagerCynet Health is seeking a skilled Travel Nurse RN Case Manager to join our team. As a Travel Nurse RN Case Manager, you will be responsible for providing high-quality patient care and managing patient cases in a fast-paced healthcare environment.Responsibilities:Perform admission, concurrent, and retrospective reviews...