Enter a job title or keyword
Utilization Management Nurse, Out of Network
Job Location:
Job Location:
Somerville, NJ - USA
Yearly Salary:
$ 90000 - 107000
Yearly Salary:
Posted:
22 August 2026 (13 days ago)
Posted:
Application Deadline:
19 November 2026
Application Deadline:
Vacancies:
1 Vacancy
Vacancies:
Job Summary
Site: Mass General Brigham Health Plan Holding Company Inc.
Mass 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 worlds 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.
The UM Nurse will support network adequacy review and authorization activities for members enrolled in ACO HMO and EPO products who require planned inpatient or outpatient services from out-of-network providers. Utilizing clinical knowledge the UM Nurse will review prior authorization requests assess medical necessity and benefit coverage render approval decisions within scope determine when physician review is required and complete determinations following physician review. The ideal candidate will have prior authorization experience in a managed care setting and possess strong commercial health plan knowledge.
Principal Duties and Responsibilities:
Expertise in clinical review for prospective concurrent retrospective utilization management reviews utilizing Interqual company policies and procedures and other resources as determined by review including physician reviews as needed for all lines of business as per departmental needs
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 Mass General Brigham Health Plan as needed.
Manage incoming requests for procedures and services including patient medical records and related clinical information.
Strong working knowledge of commercial self-insured fully insured and limited network plans.
Adherence to program departmental and organizational performance metrics including productivity.
Excellent verbal and written communication skills.
Excellent problem-solving and customer service skills.
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 multitask.
Develop and maintain effective working relationships with internal and external customers
Hold self and others accountable to meet commitments.
Sound decision-making and time management skills.
Proactive in areas of professional development personally and for the department.
Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
Proficient with Microsoft Word Excel Outlook McKesson InterQual Outlook SharePoint PC based operating system and web-based phone system.Remote399 Revolution Drive40RegularDay (United States of America)8925 Mass General Brigham Health Plan Holding Company Inc. 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 Veterans 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 .
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
Given equity this position will pay somewhere between $90000 to $107000 annually.Mass 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 worlds 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.
The UM Nurse will support network adequacy review and authorization activities for members enrolled in ACO HMO and EPO products who require planned inpatient or outpatient services from out-of-network providers. Utilizing clinical knowledge the UM Nurse will review prior authorization requests assess medical necessity and benefit coverage render approval decisions within scope determine when physician review is required and complete determinations following physician review. The ideal candidate will have prior authorization experience in a managed care setting and possess strong commercial health plan knowledge.
Principal Duties and Responsibilities:
Expertise in clinical review for prospective concurrent retrospective utilization management reviews utilizing Interqual company policies and procedures and other resources as determined by review including physician reviews as needed for all lines of business as per departmental needs
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 Mass General Brigham Health Plan as needed.
Manage incoming requests for procedures and services including patient medical records and related clinical information.
Strong working knowledge of commercial self-insured fully insured and limited network plans.
Adherence to program departmental and organizational performance metrics including productivity.
Excellent verbal and written communication skills.
Excellent problem-solving and customer service skills.
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 multitask.
Develop and maintain effective working relationships with internal and external customers
Hold self and others accountable to meet commitments.
Sound decision-making and time management skills.
Proactive in areas of professional development personally and for the department.
Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
Proficient with Microsoft Word Excel Outlook McKesson InterQual Outlook SharePoint PC based operating system and web-based phone system.
Qualifications
Education
- Associates Degree Nursing required or Bachelors Degree Nursing preferred
Licenses and Credentials
- Massachusetts Registered Nurse (RN) license required
Experience
- At least 2-3 years of utilization review experience is highly preferred
- Experience using Interqual or Milliman is highly preferred
- At least 1-2 years of experience in a payer setting is highly preferred
- At least 1-2 years of experience in an acute care setting is highly preferred
Knowledge Skills and Abilities
- Demonstrate Mass General Brigham Health Plans core brand principles of always listening challenging conventions and providing value
- Strong aptitude for technology-based solutions.
- Embrace opportunities to take the complexity out of how we work and what we deliver.
- Listen to our constituents learn and act quickly in our ongoing pursuit of meaningful innovation
- Current in healthcare trends.
- Ability to inject energy when and where its needed.
- Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
- Be accountable for delivering high-quality work. Act with a clear sense of ownership.
- Bring fresh ideas forward by actively listening to and working with employees and the people we serve.
- Communicate respectfully and professionally with colleagues
- Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
Knowledge Skills and Abilities
- Demonstrate Mass General Brigham Health Plans core brand principles of always listening challenging conventions and providing value
- Strong aptitude for technology-based solutions.
- Embrace opportunities to take the complexity out of how we work and what we deliver.
- Listen to our constituents learn and act quickly in our ongoing pursuit of meaningful innovation
- Current in healthcare trends.
- Ability to inject energy when and where its needed.
- Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
- Be accountable for delivering high-quality work. Act with a clear sense of ownership.
- Bring fresh ideas forward by actively listening to and working with employees and the people we serve.
- Communicate respectfully and professionally with colleagues
- Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
Additional Job Details (if applicable)
Working Conditions
- 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.
- This is a remote role with occasional onsite team meetings in Somerville MA.
Given equity this position will pay somewhere between $90000 to $107000 annually.
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$58656.00 - $142448.80/AnnualGrade
98TEMPEEO 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:
IC
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.
