Utilization Review Nurse – Post-Acute Care in Boston, Massachusetts - #72220 | VanderHouwen

Description

Job Id: 72220

Utilization Review Nurse – Post-Acute Care
Our client is seeking a Utilization Review Nurse with strong clinical judgment and managed care experience to support post-acute care reviews within a fast-paced utilization management environment. This individual will play a critical role in ensuring appropriate levels of care, optimizing patient outcomes, and maintaining compliance with regulatory and evidence-based guidelines. The ideal candidate brings a detail-oriented mindset, confidence in clinical decision-making, and the ability to collaborate effectively across interdisciplinary teams.

This role is fully remote.

Utilization Review Nurse – Post-Acute Care Responsibilities

• Evaluate medical necessity, level of care, and length of stay for post-acute services including inpatient rehabilitation, skilled nursing, and long-term acute care.
• Perform prior authorization, concurrent, and retrospective reviews using established clinical criteria and internal guidelines.
• Analyze clinical documentation to support determinations and ensure alignment with evidence-based standards.
• Communicate review outcomes (approvals, denials, or modifications) clearly and promptly to providers and internal stakeholders.
• Collaborate with care teams, case managers, and providers to support care planning and smooth transitions of care.
• Monitor ongoing cases for continued stay criteria and discharge readiness.
• Escalate complex or high-risk cases to Medical Directors and participate in clinical review discussions as needed.
• Ensure compliance with applicable regulatory requirements, including CMS guidelines and accreditation standards.
• Maintain accurate and timely documentation within utilization management systems.
• Contribute to quality improvement initiatives, audits, and process enhancements within utilization management.

Utilization Review Nurse – Post-Acute Care Qualifications

• Active, unrestricted Registered Nurse (RN) license; compact license strongly preferred.
• 3–5 years of clinical nursing experience required.
• Prior experience within a managed care environment required.
• Experience in utilization review, case management, or discharge planning preferred.
• Strong knowledge of post-acute care settings such as inpatient rehab, skilled nursing, or long-term acute care.
• Familiarity with clinical review criteria (e.g., InterQual) and utilization management practices.
• Understanding of managed care models, reimbursement structures, and regulatory frameworks.
• Demonstrated clinical assessment, critical thinking, and decision-making skills.
• Excellent communication and collaboration skills with the ability to engage providers effectively.
• Proficiency with electronic medical records and utilization management systems.

Compensation: (DOE)

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As an eligible contract employee with VanderHouwen, you’ll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.

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