Utilization Management Nurse, Escalation Support

Mass General Brigham Health Plan PositionMass 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 world's 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 FunctionsServes 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.
QualificationsEducationAssociate's Degree Nursing required or Bachelor's Degree Nursing preferredLicenses and CredentialsMassachusetts Registered Nurse (RN) licenseBasic Life Support (BLS) Certification preferredExperienceAt least 2-3 years of case management, utilization review, or discharge planning experience preferredKnowledge, Skills, and AbilitiesGiving 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 ConditionsWould 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 TypeRemoteWork Location399 Revolution DriveScheduled Weekly Hours40Employee TypeRegularWork ShiftDay (United States of America)Pay Range$58,656.00
- $142,448.80/AnnualGrade98TEMPAt 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 c