Hybrid Nurse Reviewer, Utilization Management

BrightonOne; Boston (MA); Hybrid; USD 90,000 - 115,000; Full time

Job summary

BrightonOne is seeking a Nurse Reviewer, Utilization Management in a hybrid role (Brighton, MA office 4 days/wk; 1 day remote). You will conduct prospective, concurrent, and retrospective medical necessity reviews using InterQual/MCG criteria under TRICARE/DHA policy.

Requires ADN/RN with 2+ years of nursing and 1+ year UM review experience; BSN preferred. Massachusetts RN license and related certifications are expected.

Qualifications

• Associate's degree in Nursing (ADN/RN) required; Bachelor's degree (BSN) preferred.
• 2+ years of clinical nursing experience.
• 1+ years of utilization management, review, or medical necessity review in managed care.
• Experience with TRICARE/ABA or ECHO is a plus but not required.
• Experience applying InterQual and/or MCG criteria.

Responsibilities

• Conduct prospective, concurrent, and retrospective reviews using InterQual/MCG criteria and TRICARE/DHA policy.
• Review prior authorization and referrals for completeness and clinical appropriateness; route non-certifiable cases to Medical Director.
• Coordinate peer-to-peer discussions and prepare case files for reconsiderations/appeals.
• Apply plan policy consistently and document criteria and rationale.
• Identify quality-of-care concerns and potential fraud, waste, and abuse per protocol.
• Perform inpatient concurrent review and monitor length of stay; assess continued necessity.
• Support discharge planning and transitions to next level of care.
• Identify candidates for case management or behavioral health referrals; coordinate warm handoffs.
• Communicate determinations with providers within regulatory timeframes and standards.
• Ensure reviews meet DHA/TRICARE timelines and accreditation requirements.
• Maintain complete documentation within UM platform and compliance.

Skills

Clinical nursing judgment

Documentation

Communication

Independent decision-making

InterQual/MCG criteria

Education

ADN/RN required

BSN preferred

Tools

MS Office Suite

EMR systems

Job description

BrightonOne is seeking a Nurse Reviewer, Utilization Management in a hybrid role (Brighton, MA office 4 days/wk; 1 day remote). You will conduct prospective, concurrent, and retrospective medical necessity reviews using InterQual/MCG criteria under TRICARE/DHA policy.

Requires ADN/RN with 2+ years of nursing and 1+ year UM review experience; BSN preferred. Massachusetts RN license and related certifications are expected.