[Hiring] Utilization Management Nurse, Escalation Support @Mass General Brigham

Role Description

Provides clinical review and escalation support for Utilization Management (UM) activities by triaging inquiries, calls, ticket submissions, and external requests - evaluating medical necessity, appropriateness of care, and compliance with regulatory and organizational guidelines. Collaborates with Nurse Reviewers, Medical Directors, providers, and interdisciplinary teams to address complex cases, facilitate timely determinations, and ensure accurate application of evidence-based criteria to appropriately answer and respond to provider, member, and interdisciplinary needs. Serves as a clinical resource for escalated authorizations, appeals, and coverage determinations while promoting quality outcomes, regulatory compliance, and member-centered care.

• Serves as the primary point of contact for escalated utilization management inquiries, ensuring timely triage, assessment, and resolution of complex provider, member, and internal stakeholder requests.
• Reviews and responds to escalated authorization, coverage determination, and service-related issues, coordinating with Nurse Reviewers, Medical Directors, and operational teams to facilitate appropriate next steps and ensure regulatory compliance.
• Monitors escalation channels, including phone calls, shared inboxes, ticketing systems, and other referral pathways, prioritizing requests based on clinical urgency, regulatory requirements, and business impact.
• Provides consultation and clinical guidance to utilization management staff regarding benefit interpretation, medical necessity criteria, workflow processes, and resolution of complex or sensitive cases.
• Identifies trends, recurring issues, and process improvement opportunities through escalation review activities, collaborating with leadership and cross-functional partners to enhance operational efficiency, provider experience, and member outcomes.

Qualifications

• Associate's Degree Nursing required or Bachelor's Degree Nursing preferred
• Massachusetts Registered Nurse (RN) license
• Basic Life Support (BLS) Certification preferred
• At least 2-3 years of case management, utilization review, or discharge planning experience 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.

Requirements

• 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.
• This is a remote role with occasional onsite team meetings in Somerville, MA.
• Scheduled Weekly Hours: 40
• Employee Type: Regular
• Work Shift: Day (United States of America)

Benefits

• Competitive salaries and a benefits package with flexible work options.
• Career growth opportunities.
• Comprehensive benefits, career advancement opportunities, differentials, premiums, and bonuses as applicable.
• Recognition programs designed to celebrate your contributions and support your professional growth.