Peer to Peer Utilization Management Nurse (32 Hours)
$58,656–$142,449 year
On-siteSomerville, Massachusetts, United States
Job Summary
Conduct detailed clinical record reviews to assess medical necessity and severity of illness for concurrent level-of-care denials, applying nationally recognized criteria like InterQual and MCG to determine appropriateness of inpatient versus observation status. Collaborate with Physician Advisors and emergency department providers to prepare cases for peer-to-peer discussions, document clinical rationale and determinations in EPIC, and manage tracking tools for review status and outcomes. Support reconsideration (CONI) processes through RN-to-RN collaboration with payers, escalate complex cases when clinical findings conflict with payer determinations, and assist with quality improvement initiatives and denial trend analysis. Work remotely 32 hours per week on a rotating schedule within standard business hours.
Required Qualifications
- Bachelor's of Science, Nursing (BSN)
- RN license for State of Massachusetts
- 5+ years clinical nursing experience in an acute care hospital setting
- 3+ years utilization review, care management or utilization management experience
- 1+ years experience applying InterQual and/or MCG criteria for level of care determination
- 1+ years experience reviewing and managing payer denials
- Ability to perform independent, complex clinical record reviews
- Experience collaborating with physicians, physician advisors, and interdisciplinary teams to resolve level of care issues
- Proficiency with electronic medical records (EPIC)
- Experience with utilization management documentation workflows
- 32 hours per week on a rotating schedule, within standard business hours
- Remote workdays, employees must use a stable, secure, and compliant workstation in a quiet environment
- Teams Video is required and must be accessed using MGB-provided equipment
Desired Qualifications
- Experience supporting or preparing cases for peer-to-peer (P2P) discussions with payers
- Certification in Utilization Review (CPUR), Case Management (CCM), or related specialty
- Experience with appeals, reconsideration (CONI) processes, or denial trend analysis
- Strong clinical background with the ability to synthesize complex medical information
- Expert-level knowledge of utilization review principles, level-of-care determination, and payer reimbursement guidelines
- Demonstrated proficiency with InterQual and/or MCG criteria
- Advanced critical thinking skills with confident, independent clinical decision-making
- Ability to influence, negotiate, and collaborate effectively with providers, physician advisors, and interdisciplinary teams
- Strong written and verbal communication skills, with emphasis on clear clinical documentation
- High level of organizational skills and ability to manage multiple complex cases simultaneously
- Comfort functions autonomously in a fast-paced, high-volume, centralized review environment
- Proficiency with EPIC and utilization management tracking tools
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