Remote Utilization Management Nurse

Mass General Brigham Health Plan, Inc.; Massachusetts; Remote; USD 5,900 - 142,000; Full time

Benefits offered by this job

Flexible work options

Career growth opportunities

Job summary

Mass General Brigham Health Plan is seeking a Clinical Utilization Management Nurse to provide escalation support, triage inquiries, and determine medical necessity and adherence to guidelines. You will collaborate with Nurse Reviewers, Medical Directors, and providers to ensure timely determinations and evidence-based care.

This is a remote role with occasional on-site meetings in Somerville, MA. A MA RN license and 2–3 years in case management or utilization review are preferred; strong

Qualifications

• Associate's Degree in Nursing or Bachelor's in Nursing preferred.
• Massachusetts RN license required.
• BLS certification preferred.
• 2–3 years of case management, utilization review, or discharge planning experience preferred.

Responsibilities

• Serve as primary contact for escalated utilization management inquiries.
• Review and respond to authorization and service issues with regulatory compliance.
• Monitor escalation channels and prioritize requests by clinical urgency.
• Provide clinical guidance to UM staff on benefit interpretation and workflows.
• Identify trends and propose process improvements to enhance efficiency.

Skills

Active listening

Analytical thinking

Rapport building

Microsoft Office

Problem solving

Confidentiality

Healthcare knowledge

Education

ASN/BSN Nursing

Tools

None

Job description

Mass General Brigham Health Plan is seeking a Clinical Utilization Management Nurse to provide escalation support, triage inquiries, and determine medical necessity and adherence to guidelines. You will collaborate with Nurse Reviewers, Medical Directors, and providers to ensure timely determinations and evidence-based care.

This is a remote role with occasional on-site meetings in Somerville, MA. A MA RN license and 2–3 years in case management or utilization review are preferred; strong