Remote RN Leader, Utilization Management & Quality

Baystate Health; Springfield (MA); Remote; USD 108,000 - 147,000; Full time

Job summary

Baystate Health’s Health New England is seeking a Manager of Utilization Management to lead our Utilization Management Health Services Team and help shape the delivery of high-quality, cost-effective, member-centered care in Springfield, MA.

The role directs a team of RNs and clinical staff across Commercial, Medicare, and Medicaid lines, driving quality improvement, regulatory compliance, and data-driven decision making to improve member outcomes while managing costs.

Qualifications

• Bachelor’s Degree in Nursing is required.
• Active RN license in Massachusetts is required.
• Minimum of 5 years in case management or utilization management.
• Demonstrated leadership and negotiation skills.
• Proficiency with data collection, analysis, and presenting findings.
• Knowledge of NCQA, regulatory standards, and Medicare/Medicaid requirements.

Responsibilities

• Lead and mentor registered nurses and clinical staff.
• Oversee utilization management across Commercial, Medicare, and Medicaid.
• Develop quality improvement activities with Medical Director.
• Monitor regulatory compliance and use data to drive improvements.
• Partner with cross-functional teams and manage vendor relationships.

Skills

Nursing

RN License

Leadership

Project management

Regulatory knowledge

Data analysis

MS Office

Communication

Problem-solving

Independence

Education

Bachelor's Degree in Nursing

Tools

Microsoft Word

Excel

PowerPoint

Access

Job description

Baystate Health’s Health New England is seeking a Manager of Utilization Management to lead our Utilization Management Health Services Team and help shape the delivery of high-quality, cost-effective, member-centered care in Springfield, MA.

The role directs a team of RNs and clinical staff across Commercial, Medicare, and Medicaid lines, driving quality improvement, regulatory compliance, and data-driven decision making to improve member outcomes while managing costs.