SCO RN UM Reviewer

NeighborHealth, formerly East Boston Neighborhood Health Center, is one of the largest community health centers in the country, serving the greater Boston area with a strong commitment to the health and well-being of our patients and communities. Every role at NeighborHealth is vital in advancing medicine and delivering the best care experience.

About the role

The Utilization Management (UM) Reviewer RN is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. This role ensures compliance with CMS standards for service decisions and organizational determinations. The position requires a comprehensive understanding of the Health Center’s mission and core values—compassion, diversity, innovation, respect—as well as initiative, critical thinking, problem-solving, leadership, and effective collaboration with the clinical team.

Responsibilities

• Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors, and members in adherence with regulatory and contractual requirements.
• Meets or exceeds timely authorization standards.
• Provides decision-making guidance to clinical teams on service planning as needed.
• Works closely with RN Case Managers and the Medical Director to facilitate escalated reviews in accordance with Standard Operating Procedures.
• Maintains consistent communication and collaboration with the CCA UM team and SCO team regarding updates and program issues; ensures Directors/Managers and peers are informed.
• Functions as a team member, including active participation in staff meetings to provide support, assistance, and feedback.
• Promotes teamwork, maintains a positive and adaptable attitude, embraces change, and fosters a culture of acceptance, support, and collegiality.
• Performs other duties as assigned; responsibilities may change with or without notice.

Requirements

• Bachelor’s degree in Nursing preferred.
• 3-5 years of progressive experience working in a health plan preferred.
• Minimum of 5 years’ experience in healthcare or multi-site clinics required.
• Strong interpersonal and communication skills, with the ability to build rapport across diverse teams.
• Solid knowledge of prior authorizations and clinical expertise to interpret clinical criteria for medical necessity.
• Exceptional problem-solving and conflict-resolution abilities.
• Ability to handle sensitive and confidential matters with professionalism and discretion.
• Proficiency in Microsoft Office Suite.
• Ability to work in a fast-paced environment.

Work Environment & Physical Requirements

• Regularly required to sit, stand, walk, and use hands to operate a computer and other office equipment.
• Must remain in a stationary position for extended periods while performing administrative and computer-based tasks.
• Occasionally required to lift or move items weighing up to 20 pounds (e.g., files, office supplies, or small equipment).
• Must have adequate visual acuity, hearing, and manual dexterity to perform essential job functions.
• Expected to follow all NeighborHealth and OSHA safety policies and procedures, including maintaining a safe and ergonomic work environment.

Pay

Starting at $44/hr up to $64/hr based on experience.

Time Type: Full time
Department: Senior Care Options (SCO)
Location: 10 Gove Street – Taylor Building