Utilization Review Nurse

Utilization Review Nurse

Mass General Brigham Health Plan Holding Company, Inc.

Job Summary

Utilization Review Nurse (UMCM) uses clinical knowledge to analyze, assess, and render approval decisions, determine need for physician review and complete determinations post‑physician review. Ideal candidate has prior authorization (outpatient review) experience in a managed care setting with Medicaid/Mass Health 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.
• Review authorization requests for medical services, including eligibility and coverage determinations, screening for medical necessity, determining additional information required, and referral to correct programs.
• Manage incoming requests for procedures and services including patient 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.
• Available for “on call” minimum once per month, potentially increasing after 6 months.
• Self‑directed, highly motivated, and able to multi‑task.
• 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 professional development.
• Persist in accomplishing objectives to consistently achieve results.
• Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people‑first organization.
• Proficient with Microsoft Word, Excel, Outlook, McKesson Inter Qual®, SharePoint, PC‑based OS, 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 highly preferred.
• Experience using Interqual or Milliman highly preferred.
• At least 1‑2 years in a payer setting highly preferred.
• At least 1‑2 years in an acute care setting highly preferred.

Knowledge, Skills, and Abilities

• Demonstrate Core brand principles of always listening, challenging conventions, and providing value.
• Strong aptitude for technology‑based solutions.
• Embrace opportunities to simplify how we work.
• Listen to constituents, learn, and act quickly in pursuit of innovation.
• Current in healthcare trends.
• Bring energy when and where needed.
• Self‑aware, monitor impact on others, receptive to feedback, use self‑discipline to adjust.
• Accountable for delivering high‑quality work with ownership.
• Forward new ideas by listening to employees and customers.
• Communicate respectfully and professionally.
• Strong emotional intelligence with self‑awareness and feedback reception.

Additional Job Details

• Available for “on call” minimum once per month, potentially increasing after 6 months.
• Remote with occasional onsite 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 – $/Annual

Grade

98

TEMP

Benefits and Compensation Overview

Mass General Brigham offers comprehensive benefits, career advancement, differentials, premiums and bonuses, recognitions, and a supportive professional growth environment.

EEO Statement

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,…