[Hiring] Utilization Management Nurse @Mass General Brigham

Role Description

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.

Qualifications

• Education:
  • Associate's Degree Nursing required; Bachelor's Degree Nursing preferred
• Licenses and Credentials:
  • Massachusetts Registered Nurse license required
  • Basic Life Support [BLS Certification] Certification preferred
• Experience:
  • 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
  • InterQual experience preferred
• Knowledge, Skills, and Abilities:
  • 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.

Requirements

• This is a remote role that can be done from most US states
• Scheduled Weekly Hours: 40
• Employee Type: Regular
• Work Shift: Day (United States of America)

Benefits

• Competitive salaries
• Flexible work options
• Career growth opportunities
• Comprehensive benefits
• Differentials, premiums, and bonuses as applicable
• Recognition programs designed to celebrate contributions and support professional growth