Canton, MA · On-site
$55 - $60/hr
Ensure all utilization review activities meet regulatory turnaround time requirements. * Collaborate with Medical Directors for complex cases, denial recommendations, and clinical escalations.
New
Canton, MA · On-site
$55 - $60/hr
Ensure all utilization review activities meet regulatory turnaround time requirements. * Collaborate with Medical Directors for complex cases, denial recommendations, and clinical escalations.
New
Responsibilities Utilization Review Coordinator Opportunity - HRI Hospital is seeking a Full-time Utilization Review Coordinator to join our skilled and dedicated team of psychiatric professionals ...
Responsibilities Utilization Review Coordinator Opportunity - HRI Hospital is seeking a Full-time Utilization Review Coordinator to join our skilled and dedicated team of psychiatric professionals ...
Responsibilities Utilization Review Coordinator Opportunity - HRI Hospital is seeking a Full-time Utilization Review Coordinator to join our skilled and dedicated team of psychiatric professionals ...
Responsibilities Utilization Review Coordinator Opportunity - HRI Hospital is seeking a Full-time Utilization Review Coordinator to join our skilled and dedicated team of psychiatric professionals ...
Tewksbury, MA · On-site
Utilization Review * Discipline: Therapy * Start Date: 08/24/2026 * Duration: 52 weeks * 40 hours per week * Shift: 8 hours, days * Employment Type: Travel Benefits: * Day 1 Insurance * Cigna medical ...
Tewksbury, MA · On-site
Utilization Review * Discipline: Therapy * Start Date: 08/24/2026 * Duration: 52 weeks * 40 hours per week * Shift: 8 hours, days * Employment Type: Travel Benefits: * Day 1 Insurance * Cigna medical ...
Responsibilities Utilization Review Coordinator Opportunity - This is a part time position, working 24 hours per week. Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require ...
New
Responsibilities Utilization Review Coordinator Opportunity - This is a part time position, working 24 hours per week. Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require ...
New
Responsibilities Utilization Review Coordinator Opportunity - This is a part time position, working 24 hours per week. Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require ...
New
Responsibilities Utilization Review Coordinator Opportunity - This is a part time position, working 24 hours per week. Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require ...
New
Responsibilities Utilization Review Coordinator Opportunity - This is a part time position, working 24 hours per week. Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require ...
New
Responsibilities Utilization Review Coordinator Opportunity - This is a part time position, working 24 hours per week. Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require ...
New
Pembroke, MA · On-site
$5.0K/mo
Responsibilities Utilization Review Coordinator Opportunity - This is a part time position, working 24 hours per week. Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require ...
New
Pembroke, MA · On-site
$5.0K/mo
Responsibilities Utilization Review Coordinator Opportunity - This is a part time position, working 24 hours per week. Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require ...
New
Boston, MA · On-site
$63.25 - $76/hr
Formulary Strategy & Utilization Review Pharmacist Shape the drug benefit landscape-analyze and optimize medication use. Key Responsibilities: * Review prescribing trends and propose cost-saving ...
Boston, MA · On-site
$63.25 - $76/hr
Formulary Strategy & Utilization Review Pharmacist Shape the drug benefit landscape-analyze and optimize medication use. Key Responsibilities: * Review prescribing trends and propose cost-saving ...
Hingham, MA · On-site
$42.18 - $51.56/hr
The Role The Physical Therapy Utilization Management Reviewer is responsible for evaluating the appropriateness and medical necessity of outpatient rehabilitation services. The position works to ...
Hingham, MA · On-site
$42.18 - $51.56/hr
The Role The Physical Therapy Utilization Management Reviewer is responsible for evaluating the appropriateness and medical necessity of outpatient rehabilitation services. The position works to ...
Hingham, MA · On-site
$42.18 - $51.56/hr
The Role The Physical Therapy Utilization Management Reviewer is responsible for evaluating the appropriateness and medical necessity of outpatient rehabilitation services. The position works to ...
Hingham, MA · On-site
$42.18 - $51.56/hr
The Role The Physical Therapy Utilization Management Reviewer is responsible for evaluating the appropriateness and medical necessity of outpatient rehabilitation services. The position works to ...
Ensures that Utilization Review nurses are consistently recommending the appropriate admission status and provides education as needed. * Interacts with physicians to manage high risk patients most ...
Ensures that Utilization Review nurses are consistently recommending the appropriate admission status and provides education as needed. * Interacts with physicians to manage high risk patients most ...
Participate in utilization management committees and work on special projects related to ... Audit case reviews to ensure compliance with utilization management policies and procedures ...
Participate in utilization management committees and work on special projects related to ... Audit case reviews to ensure compliance with utilization management policies and procedures ...
Somerville, MA · On-site
$58K - $142K/yr
Provides clinical review and escalation support for Utilization Management (UM) activities by triaging inquiries, calls, ticket submissions, and external requests- evaluating medical necessity ...
Somerville, MA · On-site
$58K - $142K/yr
Provides clinical review and escalation support for Utilization Management (UM) activities by triaging inquiries, calls, ticket submissions, and external requests- evaluating medical necessity ...
Somerville, MA · On-site
$90K - $107K/yr
Provides clinical review and escalation support for Utilization Management (UM) activities by triaging inquiries, calls, ticket submissions, and external requests- evaluating medical necessity ...
Somerville, MA · On-site
$90K - $107K/yr
Provides clinical review and escalation support for Utilization Management (UM) activities by triaging inquiries, calls, ticket submissions, and external requests- evaluating medical necessity ...
Somerville, MA · On-site
$90K - $107K/yr
Provides clinical review and escalation support for Utilization Management (UM) activities by triaging inquiries, calls, ticket submissions, and external requests- evaluating medical necessity ...
Somerville, MA · On-site
$90K - $107K/yr
Provides clinical review and escalation support for Utilization Management (UM) activities by triaging inquiries, calls, ticket submissions, and external requests- evaluating medical necessity ...
Utilization Review * Discipline: RN * Start Date: 08/24/2026 * Duration: 10 weeks * 40 hours per week * Shift: 8 hours, days * Employment Type: Travel Assignment Overview * Shift: Days, 5x8hrs
Utilization Review * Discipline: RN * Start Date: 08/24/2026 * Duration: 10 weeks * 40 hours per week * Shift: 8 hours, days * Employment Type: Travel Assignment Overview * Shift: Days, 5x8hrs
Salem, MA · On-site
$1.8K - $2.7K/wk
Utilization Review * Discipline: RN * Start Date: ASAP * Duration: 13 weeks * 36 hours per week * Shift: 12 hours * Employment Type: Travel & Requirements RN Case Manager StartDate: 8/2/2026 Pay Rate ...
Salem, MA · On-site
$1.8K - $2.7K/wk
Utilization Review * Discipline: RN * Start Date: ASAP * Duration: 13 weeks * 36 hours per week * Shift: 12 hours * Employment Type: Travel & Requirements RN Case Manager StartDate: 8/2/2026 Pay Rate ...
Hingham, MA · On-site
$104K - $127K/yr
This role directs the utilization review clinical team operations for our Commercial plans. The manager will lead a clinical team, foster a culture of excellence, and ensure delivery of medically ...
Hingham, MA · On-site
$104K - $127K/yr
This role directs the utilization review clinical team operations for our Commercial plans. The manager will lead a clinical team, foster a culture of excellence, and ensure delivery of medically ...
Sr Utilization Management Nurse Optum is a global organization that delivers care, aided by ... Review the entire medical record for accuracy, and appropriate clinical treatment * Communicate ...
Sr Utilization Management Nurse Optum is a global organization that delivers care, aided by ... Review the entire medical record for accuracy, and appropriate clinical treatment * Communicate ...
$23.24 - $27.94
2% of jobs
$27.94 - $32.64
9% of jobs
$35.86 is the 25th percentile. Wages below this are outliers.
$32.64 - $37.35
21% of jobs
The median wage is $41.15 / hr.
$37.35 - $42.05
23% of jobs
$42.05 - $46.75
13% of jobs
$50.40 is the 75th percentile. Wages above this are outliers.
$46.75 - $51.45
10% of jobs
$51.45 - $56.15
8% of jobs
$56.15 - $60.85
5% of jobs
$60.85 - $65.55
5% of jobs
$65.55 - $70.25
2% of jobs
$70.25 - $74.95
2% of jobs
$23
$45
$74
A typical day in Utilization Review involves reviewing patient medical records, evaluating the necessity and appropriateness of proposed treatments or services, and documenting recommendations based on clinical criteria and insurance policies. Utilization Review specialists often collaborate closely with physicians, nurses, and insurance representatives to gather additional information and clarify cases. While much of the role is desk-based and may include remote work options, it requires regular communication with both clinical and administrative teams. This position offers variety and challenge, as no two cases are exactly alike, and there are often opportunities to advance into supervisory or quality improvement roles within the department.
A Utilization Review (UR) job involves assessing the medical necessity, efficiency, and appropriateness of healthcare services. UR professionals, often nurses or healthcare specialists, review patient records, insurance claims, and treatment plans to ensure they meet industry standards and payer requirements. They work with healthcare providers, insurance companies, and regulatory agencies to optimize care while controlling costs. Their goal is to balance quality patient care with cost-effective resource utilization.
To thrive in Utilization Review, professionals typically need a background in nursing or healthcare, strong clinical assessment capabilities, and a thorough understanding of medical guidelines and insurance regulations. Familiarity with electronic medical records (EMR) systems and utilization management software, and often certification such as Certified Utilization Review Specialist (CURN), are important. Excellent critical thinking, attention to detail, and strong communication skills enable effective case evaluation and collaboration with healthcare teams. These skills and qualifications ensure objective, accurate decisions that support cost-effective, quality patient care within compliance standards.
$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
