Utilization Management Nurse, Escalation Support

Mass General Brigham; Somerville (MA); Remote; USD 90,000 - 107,000; Full time

Benefits offered by this job

Flexible work options

Job summary

Mass General Brigham Health Plan is seeking an experienced registered nurse for a remote Utilization Management role near Somerville, MA. You will triage inquiries, assess medical necessity, and collaborate with Nurse Reviewers, Medical Directors, providers, and teams to ensure timely determinations and compliant, evidence-based care.

The role involves escalation of authorizations and coverage determinations, guiding staff on benefit interpretation, and identifying trends for process improvement

Qualifications

• Associate's Degree in Nursing or Bachelor's in Nursing required or preferred.
• Massachusetts RN license and BLS certification preferred.
• 2–3 years of case management, utilization review, or discharge planning experience preferred.
• Proficient in Microsoft Office and industry-related software programs.

Responsibilities

• Serves as the primary point of contact for escalated utilization management inquiries, ensuring timely triage, assessment, and resolution of complex provider, member, and internal stakeholder requests.
• Reviews and responds to escalated authorization, coverage determination, and service-related issues, coordinating with Nurse Reviewers, Medical Directors, and operational teams to facilitate appropriate next steps and ensure regulatory compliance.
• Monitors escalation channels, including phone calls, shared inboxes, ticketing systems, and other referral pathways, prioritizing requests based on clinical urgency, regulatory requirements, and business impact.
• Provides consultation and clinical guidance to utilization management staff regarding benefit interpretation, medical necessity criteria, workflow processes, and resolution of complex or sensitive cases.
• Identifies trends, recurring issues, and process improvement opportunities through escalation review activities, collaborating with leadership and cross-functional partners to enhance operational efficiency, provider experience, and member outcomes.

Skills

Clinical review

Utilization management

Interdisciplinary collaboration

Regulatory compliance

Communication skills

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

Microsoft Office

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

Given equity, this position will pay somewhere between $90,000 to $107,000 annually. 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.

Provides clinical review and escalation support for Utilization Management (UM) activities by triaging inquiries, calls, ticket submissions, and external requests- evaluating medical necessity, appropriateness of care, and compliance with regulatory and organizational guidelines. Collaborates with Nurse Reviewers, Medical Directors, providers, and interdisciplinary teams to address complex cases, facilitate timely determinations, and ensure accurate application of evidence-based criteria to appropriately answer and respond to provider, member, and interdisciplinary needs. Serves as a clinical resource for escalated authorizations, appeals, and coverage determinations while promoting quality outcomes, regulatory compliance, and member-centered care.

Essential Functions

• Serves as the primary point of contact for escalated utilization management inquiries, ensuring timely triage, assessment, and resolution of complex provider, member, and internal stakeholder requests.
• Reviews and responds to escalated authorization, coverage determination, and service-related issues, coordinating with Nurse Reviewers, Medical Directors, and operational teams to facilitate appropriate next steps and ensure regulatory compliance.
• Monitors escalation channels, including phone calls, shared inboxes, ticketing systems, and other referral pathways, prioritizing requests based on clinical urgency, regulatory requirements, and business impact.
• Provides consultation and clinical guidance to utilization management staff regarding benefit interpretation, medical necessity criteria, workflow processes, and resolution of complex or sensitive cases.
• Identifies trends, recurring issues, and process improvement opportunities through escalation review activities, collaborating with leadership and cross-functional partners to enhance operational efficiency, provider experience, and member outcomes.

Qualifications

• Education Associate's Degree Nursing required or Bachelor's Degree Nursing preferred
• Licenses and Credentials Massachusetts Registered Nurse (RN) license Basic Life Support (BLS) Certification preferred
• Experience At least 2-3 years of case management, utilization review, or discharge planning experience preferred

Knowledge, Skills, and Abilities

• Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
• Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
• Ability to establish strong rapport and relationships with patients and staff.
• Proficient in Microsoft Office and industry-related software programs.
• Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
• Ability to maintain client and staff confidentiality.
• Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
• Knowledge of Healthcare and Managed Care preferred.

Additional Job Details (if applicable)

Working ConditionsWould 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. This is a remote role with occasional onsite team meetings in Somerville, MA.

Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP 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.

EEO Statement

8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline. Combat disease. Hold a hand. Help people. Impact the world. Mass General Brigham is a passionate, welcoming community where minds meet caring hearts. Come be a part of the world’s most powerful force in medicine, where every role is important in changing lives. Are you ready? Our history includes New England hospitals founded over 200 years ago, some of the first and most prestigious hospitals in the world. Built on the legacy of two leading academic medical centers, we’re more than a system—we’re leaders in the practice of medicine. Mass General Brigham is committed to serving the community. We are dedicated to enhancing patient care, teaching and research, and taking a leadership role as an integrated health care system. We recognize that increasing value and continuously improving quality are essential to maintaining excellence.