Nurse Reviewer

Summary

We are seeking a talented individual for a Nurse Reviewer (RN) to support our Massachusetts contract. Due to recent turnover, there is an immediate need for nurses who hold an active Massachusetts RN license. This role involves performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract. Responsibilities include accessing proprietary systems to audit medical records, documenting findings accurately, and providing policy and regulatory support for determinations. This position is intended for pipelining, and applications will be accepted on an ongoing basis. 

Your role in our mission

• Reviews and interprets medical records against criteria to assess appropriateness and reasonableness of care; applies critical thinking to ensure documentation supports medical necessity while meeting production and quality goals. 

• Documents decisions and rationale clearly to support findings or no findings. 

• Determines approvals or refers cases to physician consultants; processes consultant decisions and ensures denial reasons are detailed and completed within deadlines. 

• Performs prior authorization, precertification, and retrospective reviews; prepares decision letters as required. 

• Assists management in training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education. 

• Maintains current knowledge of clinical criteria guidelines and completes CEUs to maintain RN licensure. 

• Attends trainings and meetings to stay current on clinical policies, procedures, rules, and regulations. 

• Cross-trains to review multiple claim types to maintain workforce flexibility. 

• Recommends and helps implement process improvements, new audit concepts, and technology solutions to enhance production, quality, and client satisfaction. 

What we're looking for

• Proficient in computer and typing skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers. 

• Active, unrestricted RN licensure in Massachusetts required; compact multistate RN license strongly preferred. Verification will occur during post-offer background check. 

• Minimum of 5+ years clinical experience in an inpatient hospital setting required. 

• Minimum of 2+ years utilization review or claims auditing experience required. 

• Experience with Milliman or InterQual criteria required. 

• Ability to work standard business hours with frequent interactions across teams and departments. 

• Flexibility to work extended hours when needed to support business demands. 

What you should expect in this role

• This is a fully remote position. Candidates may reside anywhere within the United States but must hold and maintain an active Massachusetts RN license. 

• Full-time, permanent salaried (W-2) employee position, not a contract or short-term role. 

• Health benefits (medical, dental, vision) and paid time off begin on the first day of employment. 

• Standard Monday through Friday work schedule. 

• Remote position; employees must be located within the continental U.S. while working. 

• Work environment must be private, free of distractions, loud noises, and recording devices. 

• May require up to 10% travel depending on business needs.