Utilization Management Nurse, Extended Care Facilities

Utilization Management Clinical Reviewer

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 UMCM will utilize clinical knowledge to analyze, assess, and render approval decisions, determine the need for physician review, and complete determinations following physician review. This role is primarily responsible for conducting utilization management reviews for post-acute and extended care services, including Skilled Nursing Facility (SNF), Acute Rehabilitation, and Long-Term Acute Care Hospital (LTAC) admissions and continued stays. The ideal candidate will have prior authorization and utilization management experience in a managed care setting, with experience doing post-acute authorizations, which includes SNF (skilled nursing facility), LTAC (long-term acute care), and IPR (inpatient rehabilitation). Strong clinical judgment, familiarity with post-acute levels of care, and the ability to apply medical necessity criteria to support timely and appropriate coverage decisions are essential for success in this role.

Principal Duties and Responsibilities:

• Ensures post-acute services (rehabilitation, skilled nursing, long-term acute care, home care) are clinically appropriate and aligned with best practices.
• Guides decisions on admission, continued stay, transfer readiness, or discharge.
• Serves as a first-level screening, with physician oversight when criteria are not fully met.
• Accounts for patient severity of illness, comorbidities, and complications.
• Includes objective endpoints for recovery, plateau, or goal achievement to inform care planning.
• Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual, 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

• Post-acute utilization review experience (SNF, Rehab, LTAC) UM experience highly preferred
• 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.

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.
• Remote workdays require a stable, secure, quiet, and HIPAA-compliant workspace. This will be confirmed via Microsoft Teams video for all employees
• Monday through Friday eastern business hour required

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