Utilization Review Manager Remote Faulkner
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Job Location:
Jamaica Plain, MA - USA
Hourly Salary:
$ 41 - 100
Posted on:
11-11-2025
Vacancies:
1 Vacancy
Job Summary
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 Utilization Review Manager performs the six essential activities of Case Management:Assessment
Planning
Implementation
Coordinating
Monitoring
Reassessing
Essential Functions
-Perform utilization review to evaluate for the appropriate level of care and fax all insurance reviews timely to prevent denials.
-Collaborate with patient/family and interdisciplinary team to assess for appropriate discharge needs.
-Place and implement all aspects of referrals to all levels of post-acute care in 4 Next.
-Online documentation of interaction with the patient family and interdisciplinary team.
-Interact with various third-party payers on a daily basis. Fax clinical in payor communication to the right insurer with the right fax number in the right time frame.
-Refer cases not meeting the appropriate level of care to the Physician Advisor or EHR.
-Review for Observation status and make changes as needed. Accurately facilitate all documentation needed for Medicare status change from inpatient to observation (code 44).
-Perform and monitor for quality issues and document in R.L. solutions.
-Provide the patient or family member with a copy of the Important Message.
-Provide to the patient or representative the Observation Notification letter.
-Provide to the patient representative the Acknowledgement of disclosure obtain choices of post-acute facilities or services and signature.
-Must be able to function independently in busy environment.
-Coordinate complete and track all clinical denials and appeals.
Qualifications
- Bachelors Degree Nursing required
- MA Registered Nurse License required
- 3 year of Utilization Review and Case Management experience preferred or 4 or more years of Utilization Review and Case Management experience preferred and 5 years of Acute Care Nursing required or 6 or more of Acute Care Nursing preferred
- Staff adheres to all I C.A.R.E. Standards.
- Demonstrates knowledge skills and abilities to work with various age groups in order to provide a safe discharge plan.
- Must be able to provide care for the patient despite psychosocial educational or physical disability.
- Basic computer skills experience with Excel and Word and good computation skills.
- Ability to interact and communicate within a diverse community.
- Competent with InterQual Criteria.
- Competent in Utilization Review appeals the peer-to-peer process and Case Management.
- Use critical thinking skills in all interactions and recognize the need to be solution-driven.
- Good negotiating skills with insurance companies and third-party payers.
- Performs all aspects of discharge planning to the right environment of care timely.
- Proficient in the use of ECare.
Additional Job Details (if applicable)
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$41.36 - $100.00/HourlyGrade
RN3500EEO Statement:
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.
Required Experience:
Manager
Key Skills
- Restaurant Experience
- Customer Service
- Employee Evaluation
- Management Experience
- Math
- Employment & Labor Law
- Sanitation
- Leadership Experience
- P&L Management
- Mentoring
- Supervising Experience
- Restaurant Management
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
