Canton, MA · On-site
$55 - $60/hr
InterQual and/or MCG Guidelines * Experience reviewing outpatient clinical services. * Excellent clinical assessment and critical thinking skills. * Strong communication skills with providers and ...
New
Canton, MA · On-site
$55 - $60/hr
InterQual and/or MCG Guidelines * Experience reviewing outpatient clinical services. * Excellent clinical assessment and critical thinking skills. * Strong communication skills with providers and ...
New
Completes admission reviews using InterQual criteria. * Collaborates with providers to resolve discrepancies in medical necessity. * Documents clinical reviews in Meditech per standards. * Discharge ...
Completes admission reviews using InterQual criteria. * Collaborates with providers to resolve discrepancies in medical necessity. * Documents clinical reviews in Meditech per standards. * Discharge ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
$59.42 - $86.20/hr
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
$59.42 - $86.20/hr
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
$59.42 - $86.20/hr
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
$59.42 - $86.20/hr
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
Hanover, MA · On-site
$21 - $27/hr
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
Quick apply
Hanover, MA · On-site
$21 - $27/hr
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
Brockton, MA · On-site
$20 - $26/hr
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
Quick apply
Brockton, MA · On-site
$20 - $26/hr
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
$20.75 - $26.50/hr
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
Quick apply
$20.75 - $26.50/hr
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
... Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays. b ...
$42.4K - $54.6K
15% of jobs
$54.6K - $66.9K
8% of jobs
$68.6K is the 25th percentile. Wages below this are outliers.
$66.9K - $79.1K
15% of jobs
The median wage is $86.8K / yr.
$79.1K - $91.4K
20% of jobs
$91.4K - $103.6K
11% of jobs
$109.7K is the 75th percentile. Wages above this are outliers.
$103.6K - $115.9K
13% of jobs
$115.9K - $128.1K
5% of jobs
$128.1K - $140.3K
3% of jobs
$140.3K - $152.6K
4% of jobs
$152.6K - $164.8K
3% of jobs
$164.8K - $177.1K
3% of jobs
$42.4K
$97.2K
$177.1K
Professionals utilizing InterQual criteria are primarily responsible for reviewing medical records and assessing whether inpatient admissions, procedures, or continued stays meet established clinical guidelines. Daily tasks often include documenting findings, communicating with physicians and care teams to clarify case details, and collaborating with insurance companies regarding authorization of services. These professionals act as a key resource for ensuring compliance with industry standards and optimizing patient care pathways. Successful InterQual specialists proactively identify discrepancies and help resolve issues that might delay care or reimbursement. You can expect regular interaction with both clinical and administrative staff in a fast-paced healthcare environment.
To excel in a role focused on InterQual, such as an InterQual Specialist or Utilization Review Nurse, you need a strong background in healthcare, clinical assessment skills, and familiarity with utilization management. Proficiency in using InterQual software, electronic health records (EHRs), and knowledge of medical necessity criteria are essential, and certification in case management or utilization review is often preferred. Attention to detail, strong analytical thinking, and effective communication are critical soft skills for this position. These skills ensure accurate case evaluations, appropriate care decisions, and efficient collaboration with healthcare providers and payer organizations.
An InterQual job typically involves using InterQual criteria—a set of evidence-based guidelines—to assess medical necessity for healthcare services. Professionals in these roles, such as nurses or case managers, review patient cases to ensure treatments align with best practices and insurance requirements. They work in hospitals, insurance companies, or healthcare organizations to support utilization management and improve patient care efficiency. Strong clinical knowledge and familiarity with InterQual software are often required for these positions.
$55-$60 per hour
Canton, MA
Contract
Duration: 6 Month Contract (Possibility of Extension)
Position Overview
We are seeking an experienced Utilization Management (UM) Registered Nurse to support outpatient utilization review and prior authorization activities for a leading healthcare organization. The ideal candidate will have a strong background in managed care, utilization management, medical necessity review, prior authorization, and outpatient clinical review.
This role is responsible for reviewing medical records, evaluating the medical necessity of requested services using established clinical guidelines, collaborating with physicians and healthcare providers, and ensuring timely authorization decisions while maintaining compliance with regulatory standards.
Key Responsibilities
Perform outpatient utilization management (UM) and medical necessity reviews for prior authorization and precertification requests.
Review clinical documentation and determine benefit eligibility using evidence-based clinical guidelines and health plan policies.
Evaluate requests for outpatient procedures, surgeries, imaging, therapies, specialty medications, and other healthcare services.
Ensure all utilization review activities meet regulatory turnaround time requirements.
Collaborate with Medical Directors for complex cases, denial recommendations, and clinical escalations.
Communicate authorization decisions with physicians, provider offices, hospitals, and healthcare facilities.
Participate in appeal reviews and provide clinical recommendations when appropriate.
Maintain accurate documentation within utilization management systems.
Monitor cases for quality, compliance, and adherence to organizational policies.
Identify opportunities for process improvement and contribute to quality initiatives.
Serve as a clinical resource for internal teams regarding utilization management guidelines and medical necessity criteria.
Required Qualifications
Active, unrestricted Registered Nurse (RN) license.
Associate Degree in Nursing (ADN) required.
Minimum 5 years of RN clinical experience.
Minimum 3-5 years of Utilization Management (UM), Case Management, Prior Authorization, or Medical Management experience.
Previous Managed Care, Health Plan, Medicare, Medicaid, or Commercial Insurance experience.
Strong knowledge of:
Utilization Management (UM)
Medical Necessity Review
Prior Authorization
Precertification
InterQual and/or MCG Guidelines
Experience reviewing outpatient clinical services.
Excellent clinical assessment and critical thinking skills.
Strong communication skills with providers and interdisciplinary teams.
Ability to work independently in a remote environment.
Comfortable using multiple systems while managing a high-volume workload.
Preferred Qualifications
BSN preferred.
Experience with outpatient utilization management.
Experience using InterQual and/or MCG clinical criteria.
Experience with Medicare Advantage or Commercial Health Plans.
Previous experience with appeals, grievances, or denial reviews.
Knowledge of NCQA, CMS, and utilization management regulatory requirements.
Note:
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com .
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
AI Statement: By applying, you acknowledge that AI-assisted tools may be used during hiring.
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US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions.
It services
1,001 - 5,000 Employees
Jersey City, NJ, US
2000
