Remote Utilization Management Nurse - Case Review & Appeals

massgeneralbrigham; United States; Remote; USD 90,000 - 107,000; Full time

Job summary

Mass General Brigham Health Plan is seeking a skilled RN to provide clinical review and escalation support for Utilization Management activities. You will triage inquiries, evaluate medical necessity, and collaborate with Nurse Reviewers, medical directors, and interdisciplinary teams to ensure accurate determinations and adherence to guidelines.

The role offers a remote work option with occasional onsite meetings in Somerville, MA.

Qualifications

• Associate's Degree Nursing required or Bachelor's Degree Nursing preferred.
• Massachusetts RN license required.
• BLS certification preferred.

Responsibilities

• Serve as the primary point of contact for escalated utilization management inquiries.
• Review and respond to authorization and coverage determination issues with regulatory compliance.
• Coordinate with Nurse Reviewers, Medical Directors, and teams to ensure timely determinations.
• Provide clinical guidance to UM staff on benefit interpretation and workflow processes.
• Identify trends and opportunities for process improvement to enhance outcomes.

Skills

Clinical reasoning

Communication

Interpersonal skills

Microsoft Office

Education

Associate's Degree Nursing

Bachelor's Degree Nursing

Tools

Industry software

Job description

Mass General Brigham Health Plan is seeking a skilled RN to provide clinical review and escalation support for Utilization Management activities. You will triage inquiries, evaluate medical necessity, and collaborate with Nurse Reviewers, medical directors, and interdisciplinary teams to ensure accurate determinations and adherence to guidelines.

The role offers a remote work option with occasional onsite meetings in Somerville, MA.