Utilization Review Nurse

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 .

Location: Remote (must hold an unrestricted Massachusetts RN license) Employment Type: 5-month contract Overview: We are seeking an experienced Inpatient RN Utilization Reviewer to independently manage a clinically complex inpatient caseload across multiple care settings, including acute, subacute, rehabilitation, and LTAC. This role is responsible for determining medical necessity and benefit coverage across multiple lines of business, including government-sponsored health plans. The ideal candidate is a self-directed clinical professional with strong utilization management experience, sound judgment, and the ability to balance clinical decision-making with health plan business objectives.

Perform inpatient utilization management and discharge planning activities. Apply nationally recognized clinical criteria (e.g., InterQual, MCG) to determine medical necessity, level of care, and readiness for transition. Make timely, clinically appropriate, and cost-effective coverage determinations. Manage a complex caseload independently while collaborating with internal clinical teams. Communicate effectively with providers to facilitate care transitions across the continuum. Apply product-specific payment and reimbursement models such as DRG, case rate, or per diem structures. Identify issues requiring escalation and collaborate with leadership and cross-functional teams. Maintain accurate documentation in accordance with departmental standards. Participate in quality activities, audits, mentoring, and special projects as assigned.