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Utilization Review Np Jobs in Cape Cod, MA (NOW HIRING)

US Tech Solutions

Utilization Review Nurse

Canton, MA · On-site

$55 - $60/hr

... 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 ...

Merrimack Health

Utilization Review Nurse

Methuen, MA · On-site

... they relate to utilization review and discharge planning and payer regulations. MINIMUM EDUCATION AND EXPERIENCE: Required: * Graduate of an accredited professional nursing school * Current ...

New

Merrimack Health

Utilization Review Nurse

Lawrence, MA · On-site

... they relate to utilization review and discharge planning and payer regulations. MINIMUM EDUCATION AND EXPERIENCE: Required: * Graduate of an accredited professional nursing school * Current ...

New

Merrimack Health

Utilization Review Nurse

Methuen, MA · On-site

... they relate to utilization review and discharge planning and payer regulations. MINIMUM EDUCATION AND EXPERIENCE: Required: * Graduate of an accredited professional nursing school * Current ...

New

Beth Israel Lahey Health

Utilization Nurse

Plymouth, MA · On-site

$37.14 - $82.22/hr

Reviews admission data to establish the appropriate level of care using Interqual criteria ... Bachelor's Degree in Nursing or advanced degree in healthcare preferred. * Three years recent ...

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Utilization Review Np information

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How much do utilization review np jobs pay per hour?

As of Aug 28, 2026, the average hourly pay for utilization review np in Cape Cod, MA is $45.33, according to ZipRecruiter salary data. Most workers in this role earn between $35.82 and $52.07 per hour, depending on experience, location, and employer.

What does a utilization review nurse practitioner do?

A Utilization Review Nurse Practitioner (NP) evaluates the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They review patient records, treatment plans, and insurance coverage to ensure that care meets established guidelines and regulatory requirements. Utilization Review NPs help coordinate care, prevent unnecessary procedures, and support cost-effective healthcare delivery while ensuring patient safety and quality outcomes.

What are some common challenges utilization review nurse practitioners face when collaborating with healthcare providers and insurance companies?

Utilization Review Nurse Practitioners often navigate the challenge of balancing patient advocacy with payer requirements. They must effectively communicate clinical justifications to both healthcare providers and insurance representatives, sometimes mediating disagreements over the necessity of certain treatments or hospital stays. Staying up-to-date with ever-changing insurance guidelines and ensuring timely documentation can also be demanding, but strong organizational and interpersonal skills help facilitate smooth collaboration and successful patient outcomes.

What are the key skills and qualifications needed to thrive as a utilization review nurse practitioner, and why are they important?

To thrive as a Utilization Review Nurse Practitioner (NP), you need expert clinical judgment, a strong understanding of healthcare regulations, and advanced assessment skills, typically supported by an active NP license and clinical experience. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of insurance guidelines such as Medicare and Medicaid are commonly required. Excellent communication, attention to detail, and critical thinking are vital soft skills for effective case evaluations and collaboration with providers. These competencies ensure accurate, efficient reviews that support quality care, compliance, and cost-effective treatment decisions.

What is the difference between Utilization Review Np vs Utilization Review Nurse?

AspectUtilization Review NpUtilization Review Nurse
CredentialsMaster's degree in Nursing, Nurse Practitioner certification, state licensureRegistered Nurse (RN) license, possibly with certification in utilization review
Work EnvironmentHealthcare facilities, insurance companies, utilization review organizationsHospitals, insurance companies, outpatient clinics
Job ResponsibilitiesAssess medical necessity, authorize treatments, make clinical decisions, often with greater autonomyReview medical records, support authorization processes, follow established guidelines

Utilization Review NPs typically have advanced clinical training and greater decision-making authority compared to Utilization Review Nurses. Both roles focus on evaluating medical necessity, but NPs often perform more complex assessments and can make independent recommendations, whereas nurses support the review process under supervision or guidelines.

What are popular job titles related to Utilization Review Np jobs in Cape Cod, MA?

For Utilization Review Np jobs in Cape Cod, MA, the most frequently searched job titles are:

What job categories do people searching Utilization Review Np jobs in Cape Cod, MA look for?

The top searched job categories for Utilization Review Np jobs in Cape Cod, MA are:

What cities near Cape Cod, MA are hiring for Utilization Review Np jobs?

Cities near Cape Cod, MA with the most Utilization Review Np job openings:

Utilization Review Np jobs near you

Utilization Review Nurse

Canton, MA • On-site

US Tech Solutions
IT Services • 1 - 5K employees
Learn more about US Tech Solutionsexternal

$55 - $60/hr

Other

Posted 19 days ago

Job description

$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:

  • Candidates can be remote but must have an active unrestricted Massachusetts RN License

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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About US Tech Solutions

Sourced by ZipRecruiter

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions.

Industry

It services

Company size

1,001 - 5,000 Employees

Headquarters location

Jersey City, NJ, US

Year founded

2000

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