Utilization Management Nurse, Escalation Support
Job Location:
Somerville, NJ - USA
Yearly Salary:
Posted on:
Vacancies:
Job Summary
Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Job Summary
Given equity this position will pay somewhere between $90000 to $107000 annually.Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham we are at the forefront of transformation with one of the worlds leading integrated healthcare systems. Together we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.
Our work centers on creating an exceptional member experience a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds experiences and skills.
We are pleased to offer competitive salaries and a benefits package with flexible work options career growth opportunities and much more.
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.
Essential Functions
-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
Education
- Associates Degree Nursing required or Bachelors Degree Nursing preferred
Licenses and Credentials
- Massachusetts Registered Nurse (RN) license
- Basic Life Support (BLS) Certification preferred
Experience
- At least 2-3 years of case management utilization review or discharge planning 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.
Additional Job Details (if applicable)
Working Conditions
- 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.
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$58656.00 - $142448.80/AnnualGrade
98TEMPEEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
Required Experience:
IC
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
