Utilization Management Nurse

massgeneralbrigham; United States; On-site; USD 90,000 - 107,000; Full time

Job summary

Mass General Brigham Health Plan is seeking an experienced RN to support outpatient utilization management decisions, using InterQual criteria within a managed care setting. Massachusetts RN license required; on-call availability at least once per month; strong communication and record-management skills; competitive base pay between $90,000 and $107,000 with comprehensive benefits.

Join a not-for-profit leader committed to patient care, research and community service, with opportunities for

Qualifications

• RN license in Massachusetts required.
• Associate's Degree in Nursing or Bachelor’s Degree in Nursing preferred.
• Experience in utilization management or prior authorization in a managed care setting is a plus.
• Strong communication and documentation skills.

Responsibilities

• Perform clinical reviews for prospective, concurrent, and retrospective utilization management.
• Review authorization requests for medical services and determine medical necessity.
• Gather patient records and ensure accurate documentation.
• Maintain knowledge of commercial, self-insured, and fully insured plans.
• Collaborate with internal/external stakeholders and meet performance metrics.
• Availability for on-call shifts with monthly frequency.
• Balance multiple tasks while building strong professional relationships.

Skills

Strong communication

Documentation skills

Customer service

Multitasking

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

MS Word

Excel

Outlook

McKesson InterQual

SharePoint

PC-based OS

Web-based phone system

Job description

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.

We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.

Given equity, this position will pay somewhere between $90,000 to $107,000 annually. At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience, if applicable, education, certifications, and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package.

In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums, and bonuses as applicable, and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

The UMCM will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review as well as complete determinations following physician review. The ideal candidate will have prior authorization (outpatient review) experience in a managed care setting with commercial health plan knowledge.

Principal Duties and Responsibilities

• Expertise in clinical review for prospective, concurrent, retrospective utilization management reviews utilizing Interqual ®, company policies and procedures, and other resources as determined by review, including physician reviews as needed for all lines of business as per departmental needs
• Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within Mass General Brigham Health Plan as needed.
• Manage incoming requests for procedures and services including patient medical records and related clinical information.
• Strong working knowledge of commercial, self-insured, fully insured and limited network plans.
• Adherence to program, departmental and organizational performance metrics including productivity.
• Excellent verbal and written communication skills.
• Excellent problem solving and customer service skills.
• Would need to be available for "on call" for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire.
• Must be self-directed and highly motivated with an ability to multi-task.
• Develop and maintain effective working relationships with internal and external customers
• Hold self and others accountable to meet commitments.
• Sound decision-making and time management skills.
• Proactive in areas of professional development, personally and for the department.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
• Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual ®, Outlook, SharePoint, PC based operating system, and web-based phone system.

Qualifications

Education

Associate's Degree Nursing required or Bachelor's Degree Nursing preferred

Licenses and Credentials

Massachusetts Registered Nurse (RN) license re