DSNP Utilization Management Nurse

Mass General Brigham•Somerville, MA

1d•$58,656 - $142,449•Remote

About The Position

Mass 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. 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. Given equity, this position will pay somewhere between $90,000 to $107,000 annually. At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience, if applicable, education, certifications, and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums, and bonuses as applicable, and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. Job Summary The Medicare UM Nurse performs utilization management activities primarily for Medicare Advantage, including review of authorizations for home care, high tech radiology, outpatient, inpatient, and post-acute services. The Medicare UM Nurse reviews the medical necessity of authorization requests using NCD, LCD, Medicare Benefit Policy Manual, medical policies, and InterQual criteria.

Requirements

Associate's Degree Nursing required; Bachelor's Degree Nursing preferred
Massachusetts Registered Nurse license required
At least 2-3 years of utilization management strongly preferred
Experience applying National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and Medicare Benefit Policy Manual preferred
Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
Ability to establish strong rapport and relationships with patients and staff.
Proficient in Microsoft Office and industry related software programs.
Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
Ability to maintain client and staff confidentiality.
Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
Knowledge of Healthcare and Managed Care preferred.

Nice To Haves

Bachelor's Degree Nursing preferred
Basic Life Support [BLS Certification] Certification preferred
InterQual experience preferred

Responsibilities

The Medicare UM Nurse performs utilization management activities primarily for Medicare Advantage, including review of authorizations for home care, high tech radiology, outpatient, inpatient, and post-acute services.
The Medicare UM Nurse reviews the medical necessity of authorization requests using NCD, LCD, Medicare Benefit Policy Manual, medical policies, and InterQual criteria.