Utilization Review Manager

Job not on LinkedIn

🔥 8 minutes ago

🍂 Massachusetts – Remote

🍂 Massachusetts – Remote

💵 $41 - $100 / hour

⏱ Part Time

🟡 Mid-level

🟠 Senior

👔 Manager

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Mass General Brigham

WebsiteLinkedInAll Job Openings

10,000+ employees

📚 Education

🔬 Science

⚕️ Healthcare Insurance

Education • Science • Healthcare Insurance

Mass General Brigham is a large integrated academic healthcare system centered in Massachusetts that operates world-class hospitals, community health centers, and virtual care services, providing comprehensive patient care across specialties. It conducts extensive clinical and biomedical research, running thousands of clinical trials and advanced institutes in areas like gene and cell therapy and personalized medicine. The organization also provides medical education and training programs, workforce development, and operates a health plan and innovation/commercialization activities.

📋 Description

• Perform utilization review to evaluate for appropriate level of care • Collaborate with appropriate individuals, departments, and payers to ensure appropriateness of admission and reimbursement • Perform and monitor for quality issues and document in R.L. solutions • Communicate with attending physician and care coordination nurse around denial of care • Serve as a resource to staff and physicians about the process of denial of care for Medicare and other insurances • Coordinate, complete, and track all clinical denials and appeals

🎯 Requirements

• Bachelor's Degree in Nursing required • Massachusetts Registered Nurse License required • 5 years of Acute Care Nursing required • 3 years of Utilization Review and Case Management experience preferred • 4 or more years of Utilization Review and Case Management experience preferred • 6 or more years of Acute Care Nursing preferred • Knowledge of different industry criteria sets like Milliman and InterQual • In-depth understanding of all insurance plans, including Medicare, Medicaid • Basic computer skills, experience with Excel and Word

🏖️ Benefits

• Comprehensive benefits • Career advancement opportunities • Differentials, premiums, and bonuses as applicable • Recognition programs designed to celebrate your contributions and support your professional growth