Utilization Management Nurse: Care Coordination & Review

BrightonOne; Boston (MA); Ibrido; USD 85.000 - 110.000; Tempo pieno

Descrizione del lavoro

BrightonOne in Brighton, MA is seeking a Nurse Reviewer, Utilization Management to perform prospective, concurrent, and retrospective medical necessity reviews under TRICARE/DHA guidelines.

You will coordinate with providers and internal teams, escalate cases to the Medical Director, and support discharge planning and care coordination.

Required ADN with RN licensure in MA and 2+ years nursing, at least 1 year in UM; BSN preferred; strong documentation and communication skills.

Competenze

• Associate degree in Nursing (ADN/RN) is required; BSN preferred.
• 2+ years of clinical nursing experience.
• At least 1 year of utilization management, utilization review, or medical necessity review experience.
• Experience with InterQual and/or MCG criteria is a plus.
• Active, unrestricted RN license in Massachusetts.

Mansioni

• Conduct prospective, concurrent, and retrospective reviews using InterQual/MCG and TRICARE policies.
• Review prior authorization requests for completeness and clinical appropriateness.
• Coordinate peer-to-peer discussions and prepare case files supporting reconsiderations and appeals.
• Apply plan clinical policy and document criteria and rationale for each determination.
• Identify and refer potential quality-of-care concerns and potential fraud, waste, and abuse per protocol.
• Support discharge-planning coordination and timely transitions to the next level of care.
• Identify members for case/care management and coordinate warm handoffs.

Conoscenze

Clinical nursing expertise

Critical thinking

Communication skills

Collaboration across departments

Formazione

Associate's degree in Nursing (ADN/RN)

Bachelor's degree in Nursing (BSN) preferred

Strumenti

Electronic Medical Records (EMR)

MS Office Suite

Utilization review systems

Descrizione del lavoro

BrightonOne in Brighton, MA is seeking a Nurse Reviewer, Utilization Management to perform prospective, concurrent, and retrospective medical necessity reviews under TRICARE/DHA guidelines.

You will coordinate with providers and internal teams, escalate cases to the Medical Director, and support discharge planning and care coordination.

Required ADN with RN licensure in MA and 2+ years nursing, at least 1 year in UM; BSN preferred; strong documentation and communication skills.