Remote Utilization Management Nurse - RN Care Navigator

Mass General Brigham Incorporated; Somerville (MA); Hybrid; USD 59,000 - 142,000; Full time

Job summary

Mass General Brigham Health Plan Holding Company, Inc. is seeking an Utilization Management Nurse to perform prospective, concurrent, and retrospective reviews remotely, with occasional onsite team meetings in Somerville, MA.

The role focuses on physician review decisions and authorization determinations for commercial and managed care plans. The ideal candidate has an RN license in Massachusetts, 2–3 years in utilization review, and experience with InterQual or Milliman.

Qualifications

• RN license active in Massachusetts.
• 2–3 years utilization review experience preferred.
• Experience with InterQual or Milliman is highly preferred.

Responsibilities

• Perform prospective, concurrent, and retrospective utilization reviews.
• Review authorization requests and determine medical necessity.
• Coordinate with internal/external stakeholders and document decisions.
• Maintain knowledge of commercial, self-insured, and limited networks.

Skills

Verbal communication

Written communication

Problem solving

Customer service

Education

Associate's Degree Nursing

Bachelor's Degree Nursing

Tools

InterQual

Milliman

Job description

Mass General Brigham Health Plan Holding Company, Inc. is seeking an Utilization Management Nurse to perform prospective, concurrent, and retrospective reviews remotely, with occasional onsite team meetings in Somerville, MA.

The role focuses on physician review decisions and authorization determinations for commercial and managed care plans. The ideal candidate has an RN license in Massachusetts, 2–3 years in utilization review, and experience with InterQual or Milliman.