Remote RN Utilization Management Leader

CareSource; Boston, Northern (MA, KY); Hybrid; USD 83,000 - 133,000; Full time

Job summary

CareSource is seeking a Manager of Utilization Management in Massachusetts. The role leads the UM team, ensuring consistent application of authorization criteria and adherence to NCQA/URAC standards. Requires MA RN license and 5+ years in clinical and UM/quality roles.

Responsibilities include coordinating pre-determination, analyzing utilization trends, and ensuring regulatory compliance. A BSN is preferred; remote/hybrid options available within MA.

Qualifications

• RN license in state of practice required.
• Minimum 5 years of clinical experience.
• Minimum 5 years in one of: case management, utilization management, and/or quality improvement.
• Two years of utilization management experience preferred.

Responsibilities

• Oversee utilization management activities and ensure consistency with criteria for authorizations.
• Coordinate pre-determination processes for medical and dental services.
• Monitor productivity and utilization trends; report regulatory compliance.
• Develop and update departmental policies; ensure adverse action notices comply with regulations.

Skills

Data analysis

Communication skills

Management experience

Leadership

Time management

Detail oriented

Technical writing

Change management

Problem solving

Strategic thinking

Education

Associate's Degree in Nursing

BSN preferred

Tools

Excel

Word

PowerPoint

Job description

CareSource is seeking a Manager of Utilization Management in Massachusetts. The role leads the UM team, ensuring consistent application of authorization criteria and adherence to NCQA/URAC standards. Requires MA RN license and 5+ years in clinical and UM/quality roles.

Responsibilities include coordinating pre-determination, analyzing utilization trends, and ensuring regulatory compliance. A BSN is preferred; remote/hybrid options available within MA.