Utilization Management Nurse, Out of Network

Mass General Brigham Health Plan is an exciting place within the healthcare industry, part of one of the world’s leading integrated healthcare systems. We provide members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work focuses on creating an exceptional member experience, supported by a welcoming and collaborative environment that values diverse backgrounds, experiences, and skills.

About the role

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.

Responsibilities

• Expertise in clinical review for prospective, concurrent, and retrospective utilization management reviews using Interqual®, company policies, and other resources, including physician reviews as needed for all lines of business.
• Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity, determining if additional information is required, and referring 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.
• Adhere to program, departmental, and organizational performance metrics, including productivity.
• Develop and maintain effective working relationships with internal and external customers.
• Hold self and others accountable to meet commitments.
• Demonstrate sound decision-making and time management skills.
• Proactively pursue professional development, personally and for the department.
• Persist in accomplishing objectives despite obstacles and setbacks.
• Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.

Requirements

• Associate's Degree in Nursing required; Bachelor's Degree in Nursing preferred.
• Massachusetts Registered Nurse (RN) license required.
• 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.
• Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual®, SharePoint, PC-based operating systems, and web-based phone systems.
• Must be available for “on call” duty at least once per month, with potential for increased frequency depending on staff availability (approximately 6 months after hire).
• Self-directed, highly motivated, and able to multitask.

Skills

• Demonstrate Mass General Brigham Health Plan’s core brand principles: always listening, challenging conventions, and providing value.
• Strong aptitude for technology-based solutions.
• Ability to simplify complex processes and deliver meaningful innovation.
• Current in healthcare trends and able to inject energy where needed.
• Exercises self-awareness, monitors impact on others, and is receptive to feedback.
• Accountable for delivering high-quality work with a clear sense of ownership.
• Brings fresh ideas forward by actively listening and collaborating with colleagues and members.
• Communicates respectfully and professionally.
• Strong emotional intelligence (EQ).
• Excellent verbal and written communication skills.
• Excellent problem-solving and customer service skills.

Benefits

We offer competitive salaries, a comprehensive benefits package, flexible work options, and career growth opportunities.

Pay

This position will pay between $90,000 to $107,000 annually.

Schedule

• Scheduled weekly hours: 40
• Work shift: Day (United States of America)
• This is a remote role with occasional onsite team meetings in Somerville, MA.