Utilization Management Nurse, Out of Network

Mass General Brigham Health Plan Holding Company, Inc.; Somerville (MA); Hybrid; USD 90,000 - 107,000; Full time

Job summary

Mass General Brigham Health Plan Holding Company, Inc. is seeking a UM Nurse to support network adequacy review and prior authorization for ACO, HMO, and EPO products. Remote role with occasional onsite meetings in Somerville, MA.

Requires MA RN license and 2–3 years of utilization review experience. You will review authorization requests, determine medical necessity, collaborate with physicians, and help maintain productive relationships.

Qualifications

• RN licensure in Massachusetts is required; associate or bachelor’s degree preferred.
• Experience in utilization review and payer settings is preferred.
• Familiarity with InterQual or Milliman criteria is highly valued.

Responsibilities

• Review authorization requests for medical services and assess medical necessity.
• Determine eligibility and coverage, and refer to appropriate programs.
• Manage incoming requests and coordinate with internal/external stakeholders.
• Maintain knowledge of commercial, self-insured, fully insured, and limited network plans.
• Support on-call duties and meet departmental performance metrics.

Skills

Communication skills

Time management

Customer service

Multitasking

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Massachusetts RN license

Tools

InterQual

McKesson InterQual

SharePoint

Microsoft Word

Excel

Outlook

Job description

Company Overview

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.

The UM Nurse will support network adequacy review and authorization activities for members enrolled in ACO, HMO, and EPO products who require planned inpatient or outpatient services from out-of-network providers. Utilizing clinical knowledge, the UM Nurse will review prior authorization requests, assess medical necessity and benefit coverage, render approval decisions within scope, determine when physician review is required, and complete determinations following physician review. The ideal candidate will have prior authorization experience in a managed care setting and possess strong commercial health plan knowledge.

Essential Functions

• 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 multitask.
• 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

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

Massachusetts Registered Nurse (RN) license required.

Experience

• At least 2-3 years of utilization review experience is highly preferred
• Experience using Interqual or Milliman is highly preferred
• At least 1-2 years of experience in a payer setting is highly preferred
• At least 1-2 years of experience in an acute care setting is highly preferred

Knowledge, Skills, and Abilities

Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value Strong aptitude for technology-based solutions. Embrace opportunities to take the complexity out of how we work and what we deliver. Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation Current in healthcare trends. Ability to inject energy, when and where it’s needed. Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. Be accountable for delivering high-quality work. Act with a clear sense of ownership. Bring fresh ideas forward by actively listening to and working with employees and the people we serve. Communicate respectfully and professionally with colleagues Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Knowledge, Skills, and Abilities Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value Strong aptitude for technology-based solutions. Embrace opportunities to take the complexity out of how we work and what we deliver. Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation Current in healthcare trends. Ability to inject energy, when and where it’s needed. Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. Be accountable for delivering high-quality work. Act with a clear sense of ownership. Bring fresh ideas forward by actively listening to and working with employees and the people we serve. Communicate respectfully and professionally with colleagues Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.

Knowledge, Skills, and Abilities

Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value Strong aptitude for technology-based solutions. Embrace opportunities to take the complexity out of how we work and what we deliver. Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation Current in healthcare trends. Ability to inject energy, when and where it’s needed. Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. Be accountable for delivering high-quality work. Act with a clear sense of ownership. Bring fresh ideas forward by actively listening to and working with employees and the people we serve. Communicate respectfully and professionally with colleagues Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.

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; Approximately 6 months after hire. This is a remote role with occasional onsite team meetings in Somerville, MA. Monday through Friday, eastern business hours required. Remote workdays require a stable, secure, quiet, and HIPAA-compliant workspace. This will be confirmed via Microsoft Teams video for all employees.

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

Employment Details

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

About Us

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. 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.