Remote Utilization Management Nurse

8925 Mass General Brigham Health Plan Holding Company, Inc.; Somerville (MA); Hybrid; USD 90,000 - 107,000; Full time

Job summary

Mass General Brigham Health Plan Holding Company, Inc. in Somerville, MA is seeking a UM Nurse to support network adequacy reviews and authorization for ACO, HMO, and EPO products.

The role emphasizes clinical knowledge, medical necessity assessment, and timely determinations. The position requires an RN license and nursing degree, 2–3 years of utilization review experience, and familiarity with InterQual or Milliman.

Qualifications

• Associate degree in nursing is required or a bachelor’s degree in nursing is preferred.
• Massachusetts RN license is required.
• 2–3 years of utilization review experience is highly preferred.
• Experience using InterQual or Milliman is highly preferred.
• At least 1–2 years of payer setting experience is highly preferred.
• At least 1–2 years of acute care experience is highly preferred.

Responsibilities

• Review utilization requests and determine medical necessity and coverage.
• Render approval decisions within scope and refer to physician review as needed.
• Maintain and manage patient medical records and related information.
• Collaborate with internal teams and external providers to ensure appropriate care and authorization.
• Be available for on-call duty approximately once per month (potentially more).

Skills

Utilization review

InterQual

Milliman

RN license

Education

Associate's Degree Nursing

Bachelor's Degree Nursing

Tools

McKesson InterQual

SharePoint

MS Word/Excel

Job description

Mass General Brigham Health Plan Holding Company, Inc. in Somerville, MA is seeking a UM Nurse to support network adequacy reviews and authorization for ACO, HMO, and EPO products.

The role emphasizes clinical knowledge, medical necessity assessment, and timely determinations. The position requires an RN license and nursing degree, 2–3 years of utilization review experience, and familiarity with InterQual or Milliman.