Utilization Review Registered Nurse

Position Title: Inpatient UM Clinician (RN) Position Type: Remote Facility Location: Charlestown, MA 02129 Duration: 3 months (04/06/2026 to 07/04/2026) Shift: 8hr shift, 40hrs/ week

Compensation

Details: Gross Hourly Pay Rate: $50/hr Job Summary: The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes. Key Functions/Responsibilities:

• Performs utilization review activities, including concurrent, and retrospective reviews of inpatient cases applying evidenced-based InterQual® criteria and Medical Policy.
• Obtains clinical information using facility EMR, where accessible, to assess and expedite timely decisions.
• Determines medical appropriateness of inpatient services following evaluation of medical and contractual guidelines.
• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication.
• Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available.
• Referrals must be made in a timely manner, allowing the Physician Reviewer time to make appropriate contact with the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT).
• Monitors inpatient cases for compliance with contractual obligations and regulatory requirements, ensuring timely reviews and authorizations.
• Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures.
• Sends appropriate system-generated letters to provider and member
• Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
• Participates in discussions with the facility discharge planning team to improve the progression of care to the most appropriate level of care.
• Identify delays in care or services and manage with MD.
• Consults with the Medical Director, as needed, for complex cases.
• Follows all departmental policies and workflows in end-to-end management of cases.
• Participates in team meetings, education, discussions, and related activities
• Maintains compliance with Federal, State and accreditation organizations.
• Identifies opportunities for improved communication or processes
• May participate in audit activities and meetings
• Documents rate negotiation accurately for proper claims adjudication
• Identify and refer potential cases to Care Management
• Performs all other related duties as assigned

Qualifications:

• Active, unrestricted RN license in state of residence.

Education:

• Nursing degree or diploma required, bachelor’s degree in nursing

Preferred/Desirable:

• Bachelor’s degree
• RN license in state of MA, NH or compact license
• Medicare and Medicaid knowledge

Experience:

• 2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines)
• Managed care experience
• Experience performing discharge planning
• All employees working remotely will be required to adhere to Welleness’ Telecommuter Policy
• Ability to take after hours call, including evening/nights/weekends

Working and Physical Effort:

• Fully remote position with possible travel to the Charlestown, MA office for team meetings and training sessions.
• Fast paced and dynamic work environment requiring adaptability and focus.
• Minimal physical effort required; primarily desk-based tasks such as documentation and virtual meetings.
• Regular and reliable attendance is essential.

License: RN state of residence Job Type: Contract Pay: $50.00 per hour Expected hours: 40 per week Benefits:

• Health insurance

Application Question(s):

• Best time to give you a call on weekdays?

Education:

• Associate (Required)

Experience:

• utilization review and evidence-based (InterQual Guidelines): 2 years (Required)

License/Certification:

• RN license in state of MA, NH or compact license (Required)

Shift availability:

• Day Shift (Required)

Willingness to travel:

• 25% (Required)

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