Remote Utilization Management Nurse

Mass General Brigham; Somerville (MA); Remote; USD 90,000 - 107,000; Full time

Benefits offered by this job

Remote with occasional onsite meetings

Competitive benefits

Job summary

Mass General Brigham Health Plan Holding Company, Inc. seeks a Nurse for utilization review to assess medical necessity and benefit coverage for ACO/HMO/EPO members. Remote with occasional on-site team meetings in Somerville, MA.

Strong InterQual/Milliman experience and payer background desired. Competitive benefits and equity in a supportive, patient-centered environment. The UM Nurse will handle prior authorizations, review requests, and coordinate with clinical teams while maintaining

Qualifications

• Associate degree in nursing required; Bachelor degree preferred.
• Massachusetts RN license required.
• 2-3 years utilization review experience preferred.
• Experience with InterQual or Milliman preferred.
• 1-2 years payer setting experience preferred.
• 1-2 years acute care setting experience preferred.
• Strong communication and customer service skills.

Responsibilities

• Perform prospective, concurrent, and retrospective utilization management reviews.
• Assess medical necessity and benefit coverage; determine approvals.
• Review authorization requests and coordinate with programs.
• Ensure adherence to performance metrics and productivity targets.
• Maintain strong relationships with internal/external customers.
• Support professional development and continuous improvement.

Skills

Communication skills

Problem solving

Customer service

Teamwork

Education

Associate degree in nursing

Bachelor's degree in nursing preferred

Tools

Microsoft Word

Excel

Outlook

McKesson InterQual

SharePoint

Job description

Mass General Brigham Health Plan Holding Company, Inc. seeks a Nurse for utilization review to assess medical necessity and benefit coverage for ACO/HMO/EPO members. Remote with occasional on-site team meetings in Somerville, MA.

Strong InterQual/Milliman experience and payer background desired. Competitive benefits and equity in a supportive, patient-centered environment. The UM Nurse will handle prior authorizations, review requests, and coordinate with clinical teams while maintaining