SCO RN UM Reviewer

NeighborHealth • Boston, MA

2d • $44 - $64 • Onsite

About The Position

NeighborHealth, formerly East Boston Neighborhood Health Center, is a large community health center serving the greater Boston area with a commitment to patient and community health. Every role is vital in advancing medicine and delivering the best care experience. This position is in the Senior Care Options (SCO) department and is full-time.

The Utilization Management (UM) Reviewer RN is responsible for the day-to-day timely clinical and service authorization review for medical necessity and decision-making. This role is key in ensuring CCA meets CMS compliance 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), initiative, critical thinking, problem-solving, leadership qualities, and effective engagement with the clinical team.

Requirements

• 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 to determine medical necessity of services.
• Exceptional problem-solving and conflict-resolution abilities.
• Ability to handle sensitive and confidential matters with professionalism and discretion.
• Proficiency in Microsoft Office Suite.
• The ability to work in a fast-paced environment.
• Must be able to 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 (such as 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.

Nice To Haves

• Bachelor’s degree in Science in Nursing degree preferred
• 3-5 years of progressive experience working in a health plan preferred

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
• Meet or exceeds Timely authorizations
• Provides decision-making guidance to clinical teams on service planning as needed.
• Works closely with RN Case managers & Medical Director to facilitate escalated reviews in accordance with Standard Operating Procedures.
• Maintains consistent communication and collaboration with CCA UM team and SCO team relating to updates and program issues; ensures that Directors/Managers and peers are also informed of these matters.
• Functions as a team member, including active participation in staff meetings as appropriate to provide support, assistance, feedback.
• Promotes a sense of teamwork; maintains a positive and flexible/adaptable attitude. Open to new ideas and embraces change. Promotes a culture of acceptance, support and collegiality.

Benefits

• Equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level