When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
Utilization Review Registered Nurse (RN)
Make a Clinical Impact Beyond the Bedside
Are you an experienced RN who excels at clinical judgment, collaboration, and navigating complex systems of care? Join our Utilization Review team and play a critical role in ensuring patients receive the right level of care at the right time—while supporting quality outcomes, regulatory compliance, and financial sustainability for the organization.
As a Utilization Review RN, you’ll work closely with physicians, RN Case Managers, and interdisciplinary teams to evaluate medical necessity, optimize documentation, and support timely, safe transitions of care. Your clinical expertise will directly influence patient flow, reimbursement integrity, and hospital performance.
Job Description:
What You’ll Do
- Apply clinical expertise to conduct concurrent and retrospective utilization reviews, ensuring admissions and continued stays meet medical necessity and payer requirements.
- Partner with physicians to determine the appropriate level of care (inpatient, outpatient, observation) and support accurate, defensible documentation.
- Collaborate with RN Case Managers and interdisciplinary teams to identify barriers to discharge and promote efficient, patient‑centered care transitions.
- Proactively seek additional clinical documentation when needed to ensure the medical record fully reflects severity of illness and intensity of services.
- Support resolution of payer denials, authorizations, certifications, and appeals, contributing to reimbursement accuracy and organizational success.
- Monitor utilization trends, performance dashboards, and key metrics to identify opportunities for improvement and operational excellence.
- Participate in process improvement initiatives that enhance the effectiveness of utilization review operations.
- Assist with orientation and mentoring of new utilization review or case management team members.
- Stay current with evolving regulatory, CMS, and payer requirements, ensuring compliance and best practices are upheld.
- Contribute to the development and refinement of utilization review policies, workflows, and procedures.
Who You Are
- A licensed Registered Nurse (RN) in Massachusetts with strong clinical judgment and critical‑thinking skills
- Experienced in acute care settings with a passion for quality, compliance, and patient advocacy
- Comfortable collaborating with physicians and navigating complex clinical conversations
- Detail‑oriented, analytical, and confident interpreting medical records and utilization criteria
- Motivated to grow professionally in utilization management, case management, or healthcare operations
Qualifications
Required
- Active Massachusetts RN license
- Minimum of 3 years of recent clinical or utilization management experience
Preferred
- Bachelor’s degree in Nursing (BSN) or related healthcare field
- Experience using medical necessity criteria (e.g., InterQual, MCG)
- Three years of recent case management or utilization management experience- Preferred
- Professional certification: ACM, CCM, or CMAC
Why This Role?
- Meaningful impact on patient care quality and safety
- Opportunity to use your clinical expertise in a strategic, systems‑level role
- Strong collaboration with physicians and interprofessional teams
- Exposure to reimbursement, regulatory compliance, and performance improvement
- Ideal transition for experienced RNs seeking career growth beyond the bedside
Pay Range:
$38.11 – $98.23
The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law.
