Senior RN, Utilization Management Leader

CareSource; Massachusetts; Hybrid; USD 83,000 - 133,000; Full time

Job summary

CareSource in Massachusetts is seeking a Manager, Utilization Management to oversee all utilization management activities, ensuring services meet targets and quality standards. The role requires RN licensure, an associate degree in nursing, and at least five years of clinical experience with utilization management or quality improvement; BSN preferred.

Responsibilities include coordinating pre-determination, applying criteria for authorizations, data oversight, regulatory reporting, and

Qualifications

• RN license in state of practice is required.
• Associate’s Degree in Nursing required; BSN preferred.
• Minimum 5 years clinical experience in case management, utilization management, and/or quality improvement.
• Two years of utilization management experience preferred.

Responsibilities

• Coordinate and manage the pre-determination process for medical and dental services.
• Ensure consistent application of criteria for authorization decisions.
• Oversee utilization management data and processes to meet industry standards.
• Interact with providers to align benefits with state regulations and policies.
• Monitor productivity and utilization trends.
• Oversee CQI activities and ensure audits and feedback occur regularly.

Skills

Nursing

Leadership

Analytical skills

Communication skills

Time management

Critical thinking

Attention to detail

Education

Associate’s Degree in Nursing

BSN preferred

Tools

Excel

Word

PowerPoint

Job description

CareSource in Massachusetts is seeking a Manager, Utilization Management to oversee all utilization management activities, ensuring services meet targets and quality standards. The role requires RN licensure, an associate degree in nursing, and at least five years of clinical experience with utilization management or quality improvement; BSN preferred.

Responsibilities include coordinating pre-determination, applying criteria for authorizations, data oversight, regulatory reporting, and