RN Utilization Management Reviewer

The Role

The RN Utilization Management Reviewer is responsible for facilitating care for members with complex healthcare needs, authorizing medically necessary services at the right level of care to promote optimal health.

This position is self-directed and works independently and collaboratively, using clinical skills, principles of managed care, nationally-recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member’s benefit to provide the best quality care.

The RN Utilization Management Reviewer works with a dedicated team of medical and behavioral health managers, dietitians, pharmacists, clinicians, medical directors, and more to facilitate care.

This position can be fully remote with an in‑office requirement to work 1‑3x/month at our location in Hingham, MA.

• Conduct pre‑certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service.
• Evaluate members’ clinical status, benefits, and appropriateness for programs and sites of service to develop a cost‑effective, medically necessary plan of care.
• Pass annual Inter Qual Interrater Reliability Test.
• Collaborate with clinical utilization managers, account representatives, member service associates, dietitians, and physicians to provide high‑level care coordination.
• Interact with treatment providers, PCPs, physicians, therapists, and facilities to gather clinical information for the plan of care.
• Monitor clinical quality concerns, make referrals appropriately, identify and elevate quality of care issues.
• Understand member insurance products and benefits, regulatory and NCQA requirements.
• Identify cases for medical rounds and follow up with providers to achieve optimal outcomes.
• Support a positive workplace environment, share clinical knowledge and skills to support our diverse member population.
• Other clinical duties as assigned.

• Self‑directed, independent, adaptive, flexible, and collaborative.
• Strong analytical and problem‑solving skills.
• Excellent written and verbal communication skills.
• Proficient with multiple IT systems.
• Goal‑oriented with a sense of urgency.
• Ability to interpret complex medical information and communicate actionable conditions.
• Demonstrated cultural competence and ability to work with a diverse population.
• Willingness to learn new business and clinical skills.

• 3–5 years of relevant experience in diverse clinical healthcare settings.
• Utilization Management experience preferred.
• Active licensure in Massachusetts required; licensure in additional states a plus.
• For registered nurses only: a bachelor’s degree in BSN preferred.
• Any license restrictions must be disclosed and reviewed.

High school degree or equivalent required unless otherwise noted above.

Hourly Range: $38.49 – $47.05. The posted range is the lowest to highest salary we believe we would pay for this role at the time of posting. Pay may vary based on education, experience, performance, shift, travel requirements, and business needs.

We offer a comprehensive benefits package, including paid time off, medical/dental/vision insurance, 401(k), and wellness benefits. This job is also eligible for variable pay.

We believe in diversity, inclusion, and a collaborative work environment. If you’re passionate about transforming healthcare and bringing your true colors into a culture that values your unique perspective, we encourage you to apply.

For more details on our culture and development opportunities, visit our Company Culture page. To stay informed about opportunities, join our Talent Community.