Remote Utilization Management Nurse | Denials & Appeals

Brigham and Women's Hospital; Boston (MA); On-site; USD 58,000 - 146,000; Full time

Job summary

Brigham and Women's Hospital in Boston is seeking a Staff Nurse - Per Diem Rotating Day in Utilization Management. The role reviews denials, appeals, and ensures appropriate care levels with care coordination and finance teams.

A BSN is required with RN licensure in Massachusetts and prior utilization review experience. Responsibilities include applying Milliman/InterQual criteria, collaborating with physicians and staff, and supporting quality and financial outcomes.

Qualifications

• Bachelor's Degree in Nursing required.
• Five years hospital utilization review and medical criteria experience required.
• Experience with criteria sets such as InterQual or Milliman.
• Massachusetts Registered Nurse license required.

Responsibilities

• Utilization Management: collaborate with departments and payers to ensure appropriate admission and length of stay and reimbursement.
• Denial Management: coordinate appeals, notify departments, and document denials.
• Team Work: support care coordination, participate in reviews, and assist with finance projects.

Skills

Utilization Management

Denial Management

Team Collaboration

Clinical Assessment

Education

Bachelor's Degree Nursing

Job description

Brigham and Women's Hospital in Boston is seeking a Staff Nurse - Per Diem Rotating Day in Utilization Management. The role reviews denials, appeals, and ensures appropriate care levels with care coordination and finance teams.

A BSN is required with RN licensure in Massachusetts and prior utilization review experience. Responsibilities include applying Milliman/InterQual criteria, collaborating with physicians and staff, and supporting quality and financial outcomes.