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

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