RN Utilization Management Specialist (Remote)

Mass General Brigham Health Plan, Inc.; Somerville (MA); Hybrid; USD 59,000 - 142,000; Full time

Benefits offered by this job

Flexible work options

Career growth opportunities

Remote role with occasional onsite in-

Competitive benefits

Job summary

Mass General Brigham Health Plan is recruiting a utilization review professional to contribute to managed care operations. The role focuses on medical necessity reviews and authorization determinations across commercial and payer programs.

The ideal candidate will have RN licensure in Massachusetts, 2–3 years of utilization review experience, and familiarity with InterQual or Milliman. This position is remote with occasional onsite team meetings in Somerville, MA.

Qualifications

• Massachusetts RN license required.
• 2-3 years of utilization review experience preferred.
• Experience using InterQual or Milliman is highly preferred.
• 1-2 years in a payer setting is highly preferred.
• 1-2 years in an acute care setting is highly preferred.
• Willingness to be on-call approximately monthly.

Responsibilities

• Expertise in clinical review for prospective, concurrent, retrospective utilization management using InterQual and internal policies.
• Review authorization requests for medical services, determine eligibility and coverage, assess medical necessity.
• Manage incoming requests for procedures and access to patient records and related information.
• Maintain relationships with internal and external customers and meet performance metrics.
• Communicate effectively verbally and in writing; support on-call duties as required.

Skills

Utilization review

InterQual

Milliman

Communication skills

Time management

Education

Associate's Degree Nursing

Bachelor's Degree Nursing

Tools

Microsoft Word

Excel

Outlook

McKesson InterQual

SharePoint

Job description

Mass General Brigham Health Plan is recruiting a utilization review professional to contribute to managed care operations. The role focuses on medical necessity reviews and authorization determinations across commercial and payer programs.

The ideal candidate will have RN licensure in Massachusetts, 2–3 years of utilization review experience, and familiarity with InterQual or Milliman. This position is remote with occasional onsite team meetings in Somerville, MA.