Medicare Utilization Management Nurse
7 hours ago
Site: Mass General Brigham Health Plan Holding Company, Inc.
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
The Medicare UM Case Manager, RN 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 UMCM 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
- Massachusetts Registered Nurse license required
- Basic Life Support [BLS Certification] Certification preferred
- 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
- 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.
Working Conditions
- This is a remote role that can be done from most US states
Remote Type
Remote
Work Location
399 Revolution Drive
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
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.
EEO Statement:
Mass General Brigham Health Plan Holding Company, Inc. 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
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.
-
Medicare Utilization Management Nurse
4 days ago
Somerville, MA, United States Mass General Brigham Health Plan Full timeThe Medicare UM Case Manager, RN 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 UMCM reviews the medical necessity of authorization requests using NCD, LCD, Medicare Benefit Policy Manual, medical...
-
Medicare Utilization Management Nurse
9 hours ago
Somerville, MA, United States Mass General Brigham Health Plan Full timeThe Medicare UM Case Manager, RN 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 UMCM reviews the medical necessity of authorization requests using NCD, LCD, Medicare Benefit Policy Manual, medical...
-
Medicare Appeals and Grievances Nurse
1 week ago
Somerville, MA, United States Mass General Brigham Full timeSite: Mass General Brigham Health Plan Holding Company, Inc. 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...
-
Medicare Appeals and Grievances Nurse
2 weeks ago
Somerville, MA, United States Mass General Brigham Full timeSite: Mass General Brigham Health Plan Holding Company, Inc. 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...
-
Medicare Appeals and Grievances Nurse
2 days ago
Somerville, MA, United States Mass General Brigham Full timeSite: Mass General Brigham Health Plan Holding Company, Inc. 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...
-
Medicare Member Service Representative
6 days ago
Somerville, MA, United States Salem Hospital NSMC Full timeMedicare Member Service Representative 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...
-
Supervisor, Utilization Management
1 week ago
Somerville, MA, United States Mass General Brigham (Enterprise Services) Full timeThe supervisor will work closely with the Manager, Clinical, to oversee the daily operations of the utilization management staff. The supervisor will be responsible for the direct coaching, supervision, and evaluation of licensed clinical staff. The supervisor may be required to participate in projects across the organization to support new products or...
-
Supervisor, Utilization Management
7 days ago
Somerville, MA, United States Mass General Brigham (Enterprise Services) Full timeThe supervisor will work closely with the Manager, Clinical, to oversee the daily operations of the utilization management staff. The supervisor will be responsible for the direct coaching, supervision, and evaluation of licensed clinical staff. The supervisor may be required to participate in projects across the organization to support new products or...
-
Supervisor, Utilization Management
2 weeks ago
Somerville, MA, United States Mass General Brigham (Enterprise Services) Full timeThe supervisor will work closely with the Manager, Clinical, to oversee the daily operations of the utilization management staff. The supervisor will be responsible for the direct coaching, supervision, and evaluation of licensed clinical staff. The supervisor may be required to participate in projects across the organization to support new products or...
-
Supervisor, Utilization Management
6 days ago
Somerville, MA, United States Mass General Brigham (Enterprise Services) Full timeThe supervisor will work closely with the Manager, Clinical, to oversee the daily operations of the utilization management staff. The supervisor will be responsible for the direct coaching, supervision, and evaluation of licensed clinical staff. The supervisor may be required to participate in projects across the organization to support new products or...
