Utilization Management Nurse

Mass General Brigham Health PlanMass 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.The UMCM will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review, as well as complete determinations following physician review. The ideal candidate will have prior authorization experience in a managed care setting with Medicaid/ACO 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 needsReview 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 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 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.QualificationsAssociate's Degree Nursing required or Bachelor's Degree Nursing preferredMassachusetts Registered Nurse (RN) license requiredAt least 2-3 years of utilization review experience is highly preferredExperience using Interqual or Milliman is highly preferredAt least 1-2 years of experience in a payer setting is highly preferredAt least 1-2 years of experience in an acute care setting is highly preferredAdditional Job Details (if applicable)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.Remote399 Revolution DriveScheduled Weekly Hours 40Employee Type RegularWork Shift Day (United States of America)$58,656.00 - $142,448.80/AnnualGrade 98TEMP