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.
Qualifications
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.
Additional Job Details (if applicable)
Physical Requirements
Remote Type
Remote
Work Location
789 Central Avenue
Scheduled Weekly Hours
32
Employee Type
Regular
Work Shift
Day (United States of America)
Pay Range
$58,656.00 - $142,448.80/Annual
Grade
98TEMP
EEO Statement:
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
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.
Additional Information
Company: Mass General Brigham
Location: New Hampshire
Salary: $73,216.00 - $142,448.80 per year
Job ID:
Specialties: Utilization Review
Required Licenses: RN
Experience Level: 1-3 years
