Remote Utilization Review Nurse, P2P Expert

Mass General Brigham (Enterprise Services); Somerville (MA); On-site; USD 59,000 - 142,000; Full time

Job summary

Mass General Brigham Incorporated is seeking a Peer-to-Peer Utilization Review Nurse to join the central utilization management team. The role focuses on concurrent level-of-care denials and supports physician advisor-led peer-to-peer discussions through expert clinical analysis and standardized criteria.

It requires autonomy in handling high volumes of complex cases. The position collaborates with ED providers, admitting teams, and care management, with remote work options and a 32-hour weekly

Qualifications

• BSN required; RN license for MA.
• 5+ years clinical nursing experience in an acute care hospital setting.
• 3+ years utilization review, care management or utilization management experience.
• 1+ years experience applying InterQual and/or MCG criteria for level of care determination.
• 1+ years experience reviewing and managing payer denials, collaborating with physicians and interdisciplinary teams.
• Proficiency with EPIC and utilization management documentation workflows.

Responsibilities

• Apply nationally recognized criteria (InterQual/MCG) to evaluate payer denials and determine inpatient vs observation status.
• Perform detailed clinical record reviews to assess medical necessity and severity of illness for peer-to-peer review.
• Document clinical rationale and determinations in EPIC and tracking tools.
• Collaborate with Physician Advisors to prepare cases for peer-to-peer discussions.
• Serve as subject matter expert for utilization management and payer denial trends.
• Support reconsideration processes and escalate complex cases to Physician Advisors.
• Participate in quality improvement, denial trend analysis, and learning opportunities.

Skills

BSN

RN MA license

Clinical nursing

Utilization review

InterQual/MCG criteria

EPIC

Education

BSN

CPUR/CCM certification (preferred)

Tools

EPIC system

Job description

Mass General Brigham Incorporated is seeking a Peer-to-Peer Utilization Review Nurse to join the central utilization management team. The role focuses on concurrent level-of-care denials and supports physician advisor-led peer-to-peer discussions through expert clinical analysis and standardized criteria.

It requires autonomy in handling high volumes of complex cases. The position collaborates with ED providers, admitting teams, and care management, with remote work options and a 32-hour weekly