Utilization Management Nurse, Escalation Support

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

Job summary

Mass General Brigham Health Plan is seeking a skilled RN to provide clinical review and escalation support for Utilization Management activities. You will triage inquiries, evaluate medical necessity, and collaborate with Nurse Reviewers, medical directors, and interdisciplinary teams to ensure accurate determinations and adherence to guidelines.

The role offers a remote work option with occasional onsite meetings in Somerville, MA.

Qualifications

• Associate's Degree Nursing required or Bachelor's Degree Nursing preferred.
• Massachusetts RN license required.
• BLS certification preferred.

Responsibilities

• Serve as the primary point of contact for escalated utilization management inquiries.
• Review and respond to authorization and coverage determination issues with regulatory compliance.
• Coordinate with Nurse Reviewers, Medical Directors, and teams to ensure timely determinations.
• Provide clinical guidance to UM staff on benefit interpretation and workflow processes.
• Identify trends and opportunities for process improvement to enhance outcomes.

Skills

Clinical reasoning

Communication

Interpersonal skills

Microsoft Office

Education

Associate's Degree Nursing

Bachelor's Degree Nursing

Tools

Industry software

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, and 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.
• Understandingof diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
• Knowledgeof HealthcareandManaged Care preferred.

Additional Job Details (if applicable)

Working Conditions

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; Approximately6 months after hire.

This is a remoterolewith occasional onsite team meetings in Somerville, MA.

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