Remote Utilization Nurse - Impactful Care Decisions
Santa Barbara Cottage Hospital
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Job summary
Mass General Brigham Health Plan Holding Company, Inc. is seeking an RN-based Utilization Management Nurse to support network adequacy reviews and authorization decisions for ACO, HMO, and EPO products.
The role emphasizes medical necessity assessment and robust payer knowledge. The position requires an Associate's or Bachelor's in Nursing and a Massachusetts RN license, with 2–3 years in utilization review and familiarity with InterQual or Milliman.
Qualifications
- Associate's Degree in Nursing or Bachelor's Degree in Nursing required.
- Massachusetts RN license required.
- 2–3 years of utilization review experience preferred.
- Experience with InterQual or Milliman preferred.
- 1–2 years of payer setting experience preferred.
- 1–2 years of acute care setting experience preferred.
Responsibilities
- Perform prospective, concurrent, and retrospective utilization management reviews.
- Review authorization requests and determine medical necessity and coverage.
- Coordinate with internal/external stakeholders and manage patient records.
- Ensure adherence to program and performance metrics.
- Maintain strong communication with care teams and payers.
- Support on-call rotations as needed.
Skills
Education
Tools
Job description
Mass General Brigham Health Plan Holding Company, Inc. is seeking an RN-based Utilization Management Nurse to support network adequacy reviews and authorization decisions for ACO, HMO, and EPO products.
The role emphasizes medical necessity assessment and robust payer knowledge. The position requires an Associate's or Bachelor's in Nursing and a Massachusetts RN license, with 2–3 years in utilization review and familiarity with InterQual or Milliman.
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