Remote Utilization Management Nurse

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. is seeking a UM Nurse to support network adequacy review and prior authorization for ACO, HMO, and EPO products. Remote role with occasional onsite meetings in Somerville, MA.

Requires MA RN license and 2–3 years of utilization review experience. You will review authorization requests, determine medical necessity, collaborate with physicians, and help maintain productive relationships.

Qualifications

• RN licensure in Massachusetts is required; associate or bachelor’s degree preferred.
• Experience in utilization review and payer settings is preferred.
• Familiarity with InterQual or Milliman criteria is highly valued.

Responsibilities

• Review authorization requests for medical services and assess medical necessity.
• Determine eligibility and coverage, and refer to appropriate programs.
• Manage incoming requests and coordinate with internal/external stakeholders.
• Maintain knowledge of commercial, self-insured, fully insured, and limited network plans.
• Support on-call duties and meet departmental performance metrics.

Skills

Communication skills

Time management

Customer service

Multitasking

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Massachusetts RN license

Tools

InterQual

McKesson InterQual

SharePoint

Microsoft Word

Excel

Outlook

Job description

Mass General Brigham Health Plan Holding Company, Inc. is seeking a UM Nurse to support network adequacy review and prior authorization for ACO, HMO, and EPO products. Remote role with occasional onsite meetings in Somerville, MA.

Requires MA RN license and 2–3 years of utilization review experience. You will review authorization requests, determine medical necessity, collaborate with physicians, and help maintain productive relationships.