Remote Utilization Management Nurse – Health Plan

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

Job summary

Mass General Brigham Health Plan is seeking a nurse to support network adequacy review and authorization for ACO, HMO, and EPO products. You will review requests for medical services, assess necessity and coverage, and render decisions. Prior authorization in a managed care setting is preferred.

The role offers a competitive salary between $90,000 and $107,000 annually with flexible work options and opportunities for growth within a leading healthcare system.

Qualifications

• RN license in MA is required; ADN/BSN preferred.
• 2–3 years of utilization review experience preferred.
• Experience in payer setting and acute care preferred.

Responsibilities

• Expertise in clinical review for prospective, concurrent, and retrospective UM reviews.
• Review authorization requests, determine medical necessity and coverage.
• Maintain relationships with internal/external customers and multi-task effectively.
• Be available for on-call monthly as needed, with potential increase.

Skills

Clinical Review

InterQual

Medical Necessity

Communication

Customer Service

On-call

Multitasking

Word

Excel

Outlook

Education

ADN or BSN preferred

RN license (Massachusetts)

Tools

InterQual

McKesson InterQual

SharePoint

Job description

Mass General Brigham Health Plan is seeking a nurse to support network adequacy review and authorization for ACO, HMO, and EPO products. You will review requests for medical services, assess necessity and coverage, and render decisions. Prior authorization in a managed care setting is preferred.

The role offers a competitive salary between $90,000 and $107,000 annually with flexible work options and opportunities for growth within a leading healthcare system.