RN II Utilization Review - 32 hours

Site: Wentworth-Douglass Hospital

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

M-F between the hours of 8:30 am -5 pm and a weekend once a month.
This position is remote. Must be Tech Savvy and have UR Experience!
Salary range $73,216.00 - $142,448.80 Annually. Pay is based on experience.
Summary

Performs concurrent reviews of outpatient and inpatient claims and conducts authorization reviews for patient services. Works to support high-quality medical outcomes for patients requiring precertification or preauthorization of services.

Does this position require Patient Care?

Yes

Essential Functions
Assesses, reviews, and assigns cases for utilization review (UR).
Assists with negotiating access to care in specified targeted areas and maintains effective relationships with providers serving patients.
Supports a responsive and efficient system for the authorization of services and approval of claims.
Assists with negotiating reimbursement rates with third-party payers.
Prepares clinical information for each concurrent review using information obtained directly from the medical record.
Maintains the confidentiality of healthcare information and protects organizational value by identifying and addressing potential breaches.
Facilitates effective communication among members of the treatment team to support appropriate patient care and outcomes.
Maintains compliance with regulatory changes affecting utilization management.
Uses appropriate screening criteria, clinical knowledge, and professional judgment to assess patient needs and determine appropriate utilization of services.
Recognizes and appropriately reports cases of suspected fraud, abuse, or misutilization.
Ensures the quality, accuracy, and completeness of documentation in medical records required for utilization review.

Education
RN Bachelor's Degree required

Can this role accept experience in lieu of a degree?
No

Licenses and Credentials
Registered Nurse [RN - State License]

Experience
Utilization Review experience required - 2 or more years.
Knowledge, Skills and Abilities
- Broad knowledge of various insurances and government reimbursements.
- Excellent analytical and management skills.
- Strong written and oral communication skills.
- Familiarity with the utilization review process preferred.
- Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
- Broad knowledge of various insurances and government reimbursements is desirable.
- Work independently, be self-directed and contribute as a member of a team.

Physical Requirements

Standing Frequently (34-66%)

Walking Frequently (34-66%)

Sitting Occasionally (3-33%)

Lifting Frequently (34-66%) 35lbs+ (w/assisted device)

Carrying Frequently (34-66%) 20lbs - 35lbs

Pushing Occasionally (3-33%)

Pulling Occasionally (3-33%)

Climbing Rarely (Less than 2%)

Balancing Frequently (34-66%)

Stooping Occasionally (3-33%)

Kneeling Occasionally (3-33%)

Crouching Occasionally (3-33%)

Crawling Rarely (Less than 2%)

Reaching Frequently (34-66%)

Gross Manipulation (Handling) Frequently (34-66%)

Fine Manipulation (Fingering) Frequently (34-66%)

Feeling Constantly (67-100%)

Foot Use Rarely (Less than 2%)

Vision - Far Constantly (67-100%)

Vision - Near Constantly (67-100%)

Talking Constantly (67-100%)

Hearing Constantly (67-100%)

Remote

789 Central Avenue

32

Regular

Day (United States of America)

Pay Range

$58,656.00 - $142,448.80/Annual

Grade

98TEMP

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

1810 Wentworth-Douglass Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework