New

Utlization Management Care Manager, RN

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jun 05, 2025
The Utilization Management Care Manager (UMCM) will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review as well as complete determinations following physician review. Essential Functions * Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within the MGB Health Plan as needed. * Manage incoming requests for procedures and services, including patient medical records and related clinical information. * Adherence to program, departmental and organizational performance metrics including productivity. * Excellent communication skills both verbal and written; excellent problem-solving and customer service skills are required. * 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. * Must be self-directed and highly motivated with an ability to multi-task. * Develop and maintain effective working relationships with internal and external customers * Hold self and others accountable to meet commitments. * Ensure diversity, equity, and inclusion are integrated as a guiding principle. * Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise. * Build strong relationships and infrastructures that designate MGB Health Plan as a people-first organization. Education Associate's Degree Nursing required or Bachelor's Degree Nursing preferred Licenses and Credentials MA Registered Nurse (RN) with a current state license required Experience At least 3-5 years of utilization management experience is highly preferred UM certification (InterQual) preferred At least 1-2 years of experience in a payer setting highly preferred Experience using InterQual/Milliman 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. Working Conditions This is a remote role that can be done from most US states. It will require occasional time at the office (roughly 1x/quarter) for team meetings in Somerville, MA Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.