Utilization Management Nurse, Out of Network

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

Benefits offered by this job

Remote with occasional onsite meetings

Competitive benefits

Job summary

Mass General Brigham Health Plan Holding Company, Inc. seeks a Nurse for utilization review to assess medical necessity and benefit coverage for ACO/HMO/EPO members. Remote with occasional on-site team meetings in Somerville, MA.

Strong InterQual/Milliman experience and payer background desired. Competitive benefits and equity in a supportive, patient-centered environment. The UM Nurse will handle prior authorizations, review requests, and coordinate with clinical teams while maintaining

Qualifications

• Associate degree in nursing required; Bachelor degree preferred.
• Massachusetts RN license required.
• 2-3 years utilization review experience preferred.
• Experience with InterQual or Milliman preferred.
• 1-2 years payer setting experience preferred.
• 1-2 years acute care setting experience preferred.
• Strong communication and customer service skills.

Responsibilities

• Perform prospective, concurrent, and retrospective utilization management reviews.
• Assess medical necessity and benefit coverage; determine approvals.
• Review authorization requests and coordinate with programs.
• Ensure adherence to performance metrics and productivity targets.
• Maintain strong relationships with internal/external customers.
• Support professional development and continuous improvement.

Skills

Communication skills

Problem solving

Customer service

Teamwork

Education

Associate degree in nursing

Bachelor's degree in nursing preferred

Tools

Microsoft Word

Excel

Outlook

McKesson InterQual

SharePoint

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.

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.

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 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

Education

• Associate’s Degree Nursing required or Bachelor’s Degree Nursing preferred

Licenses and Credentials

• 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.

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.

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

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. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

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 American 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 system, and establish a strong talent pipeline.