Canton, MA · On-site
$55 - $60/hr
Previous Managed Care, Health Plan, Medicare, Medicaid, or Commercial Insurance experience. * Strong knowledge of: * Utilization Management (UM) * Medical Necessity Review * Prior Authorization
Canton, MA · On-site
$55 - $60/hr
Previous Managed Care, Health Plan, Medicare, Medicaid, or Commercial Insurance experience. * Strong knowledge of: * Utilization Management (UM) * Medical Necessity Review * Prior Authorization
Pembroke, MA · On-site
$5.0K/mo
Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require working every ... Experience in Utilization Management either with a provider, insurance or HMO organization.
Pembroke, MA · On-site
$5.0K/mo
Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require working every ... Experience in Utilization Management either with a provider, insurance or HMO organization.
Pembroke, MA · On-site
$5.0K/mo
Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require working every ... Experience in Utilization Management either with a provider, insurance or HMO organization.
Pembroke, MA · On-site
$5.0K/mo
Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require working every ... Experience in Utilization Management either with a provider, insurance or HMO organization.
Pembroke, MA · On-site
$5.0K/mo
Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require working every ... Experience in Utilization Management either with a provider, insurance or HMO organization.
Pembroke, MA · On-site
$5.0K/mo
Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require working every ... Experience in Utilization Management either with a provider, insurance or HMO organization.
Pembroke, MA · On-site
$5.0K/mo
Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require working every ... Experience in Utilization Management either with a provider, insurance or HMO organization.
Pembroke, MA · On-site
$5.0K/mo
Working hours are 8am - 4:30pm, 3 weekdays per week. The schedule will require working every ... Experience in Utilization Management either with a provider, insurance or HMO organization.
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management ... Familiarity with insurance authorization processes and managed care systems. * Excellent ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management ... Familiarity with insurance authorization processes and managed care systems. * Excellent ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management ... Familiarity with insurance authorization processes and managed care systems. * Excellent ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management ... Familiarity with insurance authorization processes and managed care systems. * Excellent ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management ... Familiarity with insurance authorization processes and managed care systems. * Excellent ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management ... Familiarity with insurance authorization processes and managed care systems. * Excellent ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management ... Familiarity with insurance authorization processes and managed care systems. * Excellent ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management ... Familiarity with insurance authorization processes and managed care systems. * Excellent ...
Boston, MA · On-site
$41.71 - $105.65/hr
... insurances. 5. Assists with the preparations of denial notices given to patients. 6. Reviews cases ... Hospital utilization review and medical criteria sets required * Five years medical or surgical ...
Boston, MA · On-site
$41.71 - $105.65/hr
... insurances. 5. Assists with the preparations of denial notices given to patients. 6. Reviews cases ... Hospital utilization review and medical criteria sets required * Five years medical or surgical ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management ... Familiarity with insurance authorization processes and managed care systems. * Excellent ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management ... Familiarity with insurance authorization processes and managed care systems. * Excellent ...
Boston, MA · On-site
$41.71 - $105.65/hr
... insurances. 5. Assists with the preparations of denial notices given to patients. 6. Reviews cases ... Hospital utilization review and medical criteria sets required * Five years medical or surgical ...
Boston, MA · On-site
$41.71 - $105.65/hr
... insurances. 5. Assists with the preparations of denial notices given to patients. 6. Reviews cases ... Hospital utilization review and medical criteria sets required * Five years medical or surgical ...
Boston, MA · On-site +1
$41.71 - $105.65/hr
... insurances. 5. Assists with the preparations of denial notices given to patients. 6. Reviews cases ... Hospital utilization review and medical criteria sets required * Five years medical or surgical ...
Boston, MA · On-site +1
$41.71 - $105.65/hr
... insurances. 5. Assists with the preparations of denial notices given to patients. 6. Reviews cases ... Hospital utilization review and medical criteria sets required * Five years medical or surgical ...
Boston, MA · On-site
$79.17 - $86.72/hr
Non-patient Care (utilization Review) Registered Nurse job at Supplemental Health Care. Boston, MA ... Full medical, dental, vision, life, and even pet insurance! * Round the clock support. No matter ...
Boston, MA · On-site
$79.17 - $86.72/hr
Non-patient Care (utilization Review) Registered Nurse job at Supplemental Health Care. Boston, MA ... Full medical, dental, vision, life, and even pet insurance! * Round the clock support. No matter ...
Plymouth, MA · On-site
$37.14 - $82.22/hr
Reviews admission data to establish the appropriate level of care using Interqual criteria ... Knowledge of government and insurance company reimbursement policies in regards to admission ...
Plymouth, MA · On-site
$37.14 - $82.22/hr
Reviews admission data to establish the appropriate level of care using Interqual criteria ... Knowledge of government and insurance company reimbursement policies in regards to admission ...
Plymouth, MA · On-site
$37.14 - $82.22/hr
Reviews admission data to establish the appropriate level of care using Interqual criteria ... Knowledge of government and insurance company reimbursement policies in regards to admission ...
Plymouth, MA · On-site
$37.14 - $82.22/hr
Reviews admission data to establish the appropriate level of care using Interqual criteria ... Knowledge of government and insurance company reimbursement policies in regards to admission ...
Review the entire medical record for accuracy, and appropriate clinical treatment * Communicate ... Proven knowledge of healthcare insurance industry (Medicaid, Medicare, CMS) * Demonstrated ...
Review the entire medical record for accuracy, and appropriate clinical treatment * Communicate ... Proven knowledge of healthcare insurance industry (Medicaid, Medicare, CMS) * Demonstrated ...
Review the entire medical record for accuracy, and appropriate clinical treatment * Communicate ... Proven knowledge of healthcare insurance industry (Medicaid, Medicare, CMS) * Demonstrated ...
Review the entire medical record for accuracy, and appropriate clinical treatment * Communicate ... Proven knowledge of healthcare insurance industry (Medicaid, Medicare, CMS) * Demonstrated ...
Review the entire medical record for accuracy, and appropriate clinical treatment * Communicate ... Proven knowledge of healthcare insurance industry (Medicaid, Medicare, CMS) * Demonstrated ...
Review the entire medical record for accuracy, and appropriate clinical treatment * Communicate ... Proven knowledge of healthcare insurance industry (Medicaid, Medicare, CMS) * Demonstrated ...
Review the entire medical record for accuracy, and appropriate clinical treatment * Communicate ... Proven knowledge of healthcare insurance industry (Medicaid, Medicare, CMS) * Demonstrated ...
Review the entire medical record for accuracy, and appropriate clinical treatment * Communicate ... Proven knowledge of healthcare insurance industry (Medicaid, Medicare, CMS) * Demonstrated ...
$16.54 - $20.20
14% of jobs
$23.22 is the 25th percentile. Wages below this are outliers.
$20.20 - $23.85
14% of jobs
$23.85 - $27.51
17% of jobs
The median wage is $29.52 / hr.
$27.51 - $31.16
11% of jobs
$31.16 - $34.82
8% of jobs
$34.82 - $38.47
6% of jobs
$41.21 is the 75th percentile. Wages above this are outliers.
$38.47 - $42.13
7% of jobs
$42.13 - $45.78
7% of jobs
$45.78 - $49.44
5% of jobs
$49.44 - $53.09
5% of jobs
$53.09 - $56.75
5% of jobs
$16
$33
$56
| Aspect | Weekday Insurance Utilization Review | Weekday Claims Processor |
|---|---|---|
| Primary Role | Assessing medical necessity and appropriateness of services | Processing and reviewing insurance claims for payment |
| Credentials | Often requires healthcare or insurance certifications | Typically requires insurance or administrative experience |
| Work Environment | Healthcare settings, insurance companies | Insurance companies, healthcare offices |
| Focus | Medical review and authorization | Claims data entry and verification |
Weekday Insurance Utilization Review focuses on evaluating medical necessity, while Weekday Claims Processors handle the administrative processing of insurance claims. Both roles are essential in the insurance industry but serve different functions related to claims management and healthcare authorization.
$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
