Remote Utilization Management Nurse — Drive Care Decisions

Partner's Healthcare; Somerville (MA); On-site; USD 90,000 - 107,000; Full time

Job summary

Mass General Brigham Health Plan is seeking a UM Nurse to support network adequacy review and authorization activities for members enrolled in ACO, HMO, and EPO products who require planned services from out-of-network providers. The role emphasizes clinical knowledge, medical necessity determinations, and program referrals within a managed care setting.

The position is remote with occasional onsite team meetings in Somerville, MA, offering competitive pay and benefits.

Qualifications

• RN license required in Massachusetts
• 2-3 years of utilization review experience preferred
• Experience using InterQual or Milliman preferred
• Experience in payer setting and acute care settings preferred
• Strong communication and problem-solving skills
• Ability to be on-call once per month initially

Responsibilities

• Review prior authorization requests for medical services and determine medical necessity and coverage
• Assess eligibility and coverage, determine information needs, and refer to programs within Mass General Brigham Health Plan
• Handle incoming requests for procedures and review patient medical records and related information
• Maintain strong knowledge of commercial, self-insured, fully insured, and limited network plans
• Meet performance metrics and demonstrate strong customer service and professionalism

Education

Associate's Degree Nursing (required) or Bachelor's Degree Nursing (preferred)

Tools

InterQual / Milliman

Job description

Mass General Brigham Health Plan is seeking a UM Nurse to support network adequacy review and authorization activities for members enrolled in ACO, HMO, and EPO products who require planned services from out-of-network providers. The role emphasizes clinical knowledge, medical necessity determinations, and program referrals within a managed care setting.

The position is remote with occasional onsite team meetings in Somerville, MA, offering competitive pay and benefits.