Utilization Review Nurse

Mass General Brigham•Somerville, MA

1d•Remote

About The Position

The UMCM will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review as well as complete determinations following physician review. The ideal candidate will have prior authorization (outpatient review) experience in a managed care setting with Medicaid/MassHealth knowledge.

Requirements

Associate's Degree Nursing required or Bachelor's Degree 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
Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value
Strong aptitude for technology-based solutions. Embrace opportunities to take the complexity out of how we work and what we deliver.
Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation
Current in healthcare trends.
Ability to inject energy, when and where it’s needed.
Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
Be accountable for delivering high-quality work. Act with a clear sense of ownership.
Bring fresh ideas forward by actively listening to and working with employees and the people we serve.
Communicate respectfully and professionally with colleagues
Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.

Responsibilities

Expertise in clinical review for prospective, concurrent, retrospective utilization management reviews utilizing Interqual ®, company policies and procedures, and other resources as determined by review, including physician reviews as needed for all lines of business as per departmental needs
Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral 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.
Adherence to program, departmental and organizational performance metrics including productivity.
Excellent verbal and written communication skills.
Excellent problem solving and customer service skills.
Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire.
Must be self-directed and highly motivated with an ability to multi-task.
Develop and maintain effective working relationships with internal and external customers
Hold self and others accountable to meet commitments.
Sound decision-making and time management skills.
Proactive in areas of professional development, personally and for the department.
Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual ®, Outlook, SharePoint, PC based operating system, and web-based phone system.