Remote Utilization Management Nurse: Clinical Triage & Appeals

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

Benefits offered by this job

Flexible work options

Job summary

Mass General Brigham Health Plan is seeking an experienced registered nurse for a remote Utilization Management role near Somerville, MA. You will triage inquiries, assess medical necessity, and collaborate with Nurse Reviewers, Medical Directors, providers, and teams to ensure timely determinations and compliant, evidence-based care.

The role involves escalation of authorizations and coverage determinations, guiding staff on benefit interpretation, and identifying trends for process improvement

Qualifications

• Associate's Degree in Nursing or Bachelor's in Nursing required or preferred.
• Massachusetts RN license and BLS certification preferred.
• 2–3 years of case management, utilization review, or discharge planning experience preferred.
• Proficient in Microsoft Office and industry-related software programs.

Responsibilities

• Serves as the primary point of contact for escalated utilization management inquiries, ensuring timely triage, assessment, and resolution of complex provider, member, and internal stakeholder requests.
• Reviews and responds to escalated authorization, coverage determination, and service-related issues, coordinating with Nurse Reviewers, Medical Directors, and operational teams to facilitate appropriate next steps and ensure regulatory compliance.
• Monitors escalation channels, including phone calls, shared inboxes, ticketing systems, and other referral pathways, prioritizing requests based on clinical urgency, regulatory requirements, and business impact.
• Provides consultation and clinical guidance to utilization management staff regarding benefit interpretation, medical necessity criteria, workflow processes, and resolution of complex or sensitive cases.
• Identifies trends, recurring issues, and process improvement opportunities through escalation review activities, collaborating with leadership and cross-functional partners to enhance operational efficiency, provider experience, and member outcomes.

Skills

Clinical review

Utilization management

Interdisciplinary collaboration

Regulatory compliance

Communication skills

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

Microsoft Office

Job description

Mass General Brigham Health Plan is seeking an experienced registered nurse for a remote Utilization Management role near Somerville, MA. You will triage inquiries, assess medical necessity, and collaborate with Nurse Reviewers, Medical Directors, providers, and teams to ensure timely determinations and compliant, evidence-based care.

The role involves escalation of authorizations and coverage determinations, guiding staff on benefit interpretation, and identifying trends for process improvement