Role Description
The Peer-to-Peer (P2P) Utilization Review Nurse is an integral member of the MGB Central Utilization Management team, specializing in identifying, preparing, and clinically reviewing cases requiring peer-to-peer engagement with payers. This role focuses on concurrent level-of-care denials and supports physician advisor–led peer-to-peer discussions through expert clinical analysis, application of nationally recognized criteria, and comprehensive documentation.
The P2P Utilization Review Nurse functions with a high degree of autonomy and clinical judgment, managing a high volume of complex cases across multiple entities. Working in close collaboration with Physician Advisors, Emergency Department providers, admitting teams, Care Management, and non-clinical UM partners, this role ensures accurate level-of-care determinations, supports appeal and reconsideration pathways, and promotes consistent, compliant utilization practices. The P2P Utilization Review Nurse reports to Utilization Management leadership within the centralized UM structure.
Primary Responsibilities:
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Apply nationally recognized criteria (InterQual and/or MCG) and organizational guidelines to evaluate payer denials and determine appropriateness of inpatient versus observation status.
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Perform detailed clinical record reviews to assess medical necessity, intensity of service, and severity of illness in preparation for peer-to-peer review and identify cases appropriate for peer-to-peer review versus downgrade or reconsideration (CONI), using established exclusionary criteria and the P2P Standard of Work.
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Document clinical rationale, level-of-care determinations, and recommendations clearly and accurately in EPIC, utilization management notes, and designated tracking tools, and maintain and update required P2P tracking tools, including documenting review status, outcomes, and next steps in accordance with standardized workflows.
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Collaborate closely with Physician Advisors to prepare cases for peer-to-peer discussions, including participation in scheduled prep meetings and real-time clinical clarification.
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Serve as a subject matter expert for utilization management, payer denial trends, and peer-to-peer workflows for internal stakeholders and communicate effectively with Emergency Department providers, admitting providers, Care Managers, and UM colleagues to ensure alignment on patient class determinations and care progression.
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Support reconsideration (CONI) processes through RN-to-RN collaboration with payers when new or additional clinical information becomes available, and escalate complex or unresolved cases to Physician Advisors when payer determinations conflict with clinical findings or established criteria.
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Assist with departmental needs during periods of high demand, including additional reviews, appeal preparation, and workflow support, and participate in quality improvement initiatives, denial trend analysis, and identification of learning opportunities related to utilization management and peer-to-peer outcomes.
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Complete special assignments and projects demonstrating expert-level knowledge of utilization review criteria and peer-to-peer processes.
Qualifications
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Required: Bachelor's of Science, Nursing (BSN)
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RN license
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5+ years clinical nursing experience in an acute care hospital setting
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3+ years utilization review, care management or utilization management experience
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1+ years experience applying InterQual and/or MCG criteria for level of care determination
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1+ years experience reviewing and managing payer denials, ability to perform independent, complex clinical record reviews, and experience collaborating with physicians, physician advisors, and interdisciplinary teams to resolve level of care issues
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Proficiency with electronic medical records (EPIC preferred) and utilization management documentation workflows
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Preferred: Experience supporting or preparing cases for peer-to-peer (P2P) discussions with payers
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Certification in Utilization Review (CPUR), Case Management (CCM), or related specialty
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Experience with appeals, reconsideration (CONI) processes, or denial trend analysis
Additional Knowledge, Skills and Abilities
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Strong clinical background with the ability to synthesize complex medical information.
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Expert-level knowledge of utilization review principles, level-of-care determination, and payer reimbursement guidelines.
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Demonstrated proficiency with InterQual and/or MCG criteria.
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Advanced critical thinking skills with confident, independent clinical decision-making.
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Ability to influence, negotiate, and collaborate effectively with providers, physician advisors, and interdisciplinary teams.
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Strong written and verbal communication skills, with emphasis on clear clinical documentation.
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High level of organizational skills and ability to manage multiple complex cases simultaneously.
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Comfort functions autonomously in a fast-paced, high-volume, centralized review environment.
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Proficiency with EPIC and utilization management tracking tools.
Additional Job Details
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Schedule and Work Model: Remote / Work from Home.
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32 hours per week on a rotating schedule, within standard business hours.
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On 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.
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Remote Type: Remote
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Work Location: 399 Revolution Drive
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Scheduled Weekly Hours: 32
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Employee Type: Regular
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Work Shift: Day (United States of America)
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Pay Range: $58,656.00 - $142,448.80/Annual
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Grade: 98TEMP
