Remote Utilization Review Nurse

your Jared; Somerville, Northern (MA, KY); Hybrid; USD 90,000 - 107,000; Full time

Job summary

Mass General Brigham Health Plan Holding Company, Inc. is seeking a Remote UM Nurse to support network adequacy review and authorization activities for members in ACO, HMO, and EPO products.

The role requires clinical knowledge to review prior authorization requests, assess medical necessity, and render decisions within scope. The position offers a competitive salary range of $90,000 to $107,000 annually, with a remote work option and occasional onsite meetings.

Qualifications

• Education: Associate's Degree Nursing required or Bachelor's Degree Nursing preferred.
• Licenses: Massachusetts RN license required.
• Experience: 2–3 years of utilization review experience preferred.
• Experience: InterQual or Milliman experience preferred.
• Experience: 1–2 years in payer setting preferred.
• Experience: 1–2 years in acute care setting preferred.

Responsibilities

• Provide utilization management reviews for prospective, concurrent, and retrospective cases.
• Review authorizations for medical services and determine medical necessity and coverage.
• Coordinate with internal programs and review clinical information and records.
• Maintain relationships with internal and external customers.
• Meet productivity and performance metrics.

Skills

Verbal communication

Written communication

Time management

Multitasking

Customer service

Problem solving

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

InterQual

Milliman

Microsoft Word

Excel

Outlook

SharePoint

Job description

Mass General Brigham Health Plan Holding Company, Inc. is seeking a Remote UM Nurse to support network adequacy review and authorization activities for members in ACO, HMO, and EPO products.

The role requires clinical knowledge to review prior authorization requests, assess medical necessity, and render decisions within scope. The position offers a competitive salary range of $90,000 to $107,000 annually, with a remote work option and occasional onsite meetings.