Utilization Management Nurse, Escalation Support

Mass General Brigham•Somerville, MA

1d•$58,656 - $142,449•Remote

About The Position

Mass General Brigham Health Plan is part of Mass General Brigham, an integrated healthcare system focused on providing members with innovative solutions for their health needs and expanding access to seamless, affordable care and coverage. The organization emphasizes an exceptional member experience and offers a welcoming, supportive environment, flexible work options, career growth opportunities, and a benefits package. The Utilization Management Nurse provides clinical review and escalation support for utilization management activities. The role triages inquiries, calls, ticket submissions, and external requests; evaluates medical necessity, appropriateness of care, and compliance with regulatory and organizational guidelines; and collaborates with Nurse Reviewers, Medical Directors, providers, and interdisciplinary teams to address complex cases and facilitate timely determinations. The nurse serves as a clinical resource for escalated authorizations, appeals, and coverage determinations while promoting quality outcomes, regulatory compliance, and member-centered care. This is a remote role with occasional onsite team meetings in Somerville, Massachusetts. The position is scheduled for 40 hours per week on the day shift. Beginning approximately six months after hire, the nurse must be available for on-call coverage at least once per month, with the possibility of increased frequency depending on staff availability. The posting states an annual pay range of $58,656 to $142,448.80 and also indicates an expected range of $90,000 to $107,000 annually, subject to equity and other compensation factors.

Requirements

Associate's degree in Nursing required; Bachelor's degree in Nursing preferred.
Massachusetts Registered Nurse (RN) license.
Give full attention to others, understand their points, ask appropriate questions, and avoid interrupting at inappropriate times.
Use logic and reasoning to evaluate the strengths and weaknesses of alternative solutions, conclusions, or approaches.
Ability to establish strong rapport and relationships with patients and staff.
Proficiency in Microsoft Office and industry-related software programs.
Ability to identify complex problems, review related information, develop and evaluate options, and implement solutions.
Ability to maintain client and staff confidentiality.
Understanding of diagnostic criteria for dual conditions and ability to conceptualize modalities and placement criteria within the continuum of care.

Nice To Haves

Basic Life Support (BLS) certification.
At least 2–3 years of case management, utilization review, or discharge planning experience.
Knowledge of healthcare and managed care.

Responsibilities

Serve as the primary point of contact for escalated utilization management inquiries and ensure timely triage, assessment, and resolution of complex requests from providers, members, and internal stakeholders.
Review and respond to escalated authorization, coverage determination, and service-related issues, coordinating with Nurse Reviewers, Medical Directors, and operational teams to determine appropriate next steps and maintain regulatory compliance.
Monitor escalation channels, including phone calls, shared inboxes, ticketing systems, and other referral pathways, and prioritize requests based on clinical urgency, regulatory requirements, and business impact.
Provide utilization management staff with consultation and clinical guidance on benefit interpretation, medical necessity criteria, workflows, and complex or sensitive cases.
Identify trends, recurring issues, and process improvement opportunities through escalation reviews, collaborating with leadership and cross-functional partners to improve operational efficiency, provider experience, and member outcomes.