Remote Post-Acute Utilization Review Nurse

Partner's Healthcare; Somerville (MA); On-site; USD 90,000 - 107,000; Full time

Job summary

Mass General Brigham Health Plan is seeking a Registered Nurse to join our UM team. The UM Analyst will conduct post-acute utilization reviews for SNF, LTAC, rehab, and home care, applying medical necessity criteria to determine coverage decisions.

The ideal candidate has 2–3 years of UM/post-acute experience, solid knowledge of InterQual or Milliman guidelines, and an active Massachusetts RN license. This is a remote role with occasional onsite meetings in Somerville, MA.

Qualifications

• Post-acute utilization review experience required.
• 2-3 years of UM experience preferred.
• Active Massachusetts RN license required.

Responsibilities

• Ensure post-acute services are clinically appropriate and aligned with best practices.
• Guide admission, continued stay, transfer readiness, or discharge decisions.
• Serve as first-level screening with physician oversight when criteria are not met.
• Account for severity of illness and comorbidities in decisions.
• Apply medical necessity criteria to inform coverage decisions.
• Utilize Word, Excel, Outlook, SharePoint and InterQual in everyday tasks.

Education

Associate's Degree Nursing required

Bachelor's Degree Nursing preferred

Tools

McKesson InterQual

Milliman

Microsoft Word

Excel

Outlook

SharePoint

Job description

Mass General Brigham Health Plan is seeking a Registered Nurse to join our UM team. The UM Analyst will conduct post-acute utilization reviews for SNF, LTAC, rehab, and home care, applying medical necessity criteria to determine coverage decisions.

The ideal candidate has 2–3 years of UM/post-acute experience, solid knowledge of InterQual or Milliman guidelines, and an active Massachusetts RN license. This is a remote role with occasional onsite meetings in Somerville, MA.