Job description
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
Responsibilities
- 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.
Requirements
- RN Bachelor's Degree required
Can this role accept experience in lieu of a degree?
No
Licenses and Credentials
Registered Nurse [RN - State License]
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
• Standing Frequently (34-66%)
• Walking Frequently (34-66%)
• Sitting Occasionally (3-33%)
• Lifting Frequently (34-66%) 35lbs+ (w/assisted device)
• Carrying Frequently (34-66%) 20lbs - 35lbs
• Pushing Occasionally (3-33%)
• Pulling Occasionally (3-33%)
• Climbing Rarely (Less than 2%)
• Balancing Frequently (34-66%)
• Stooping Occasionally (3-33%)
• Kneeling Occasionally (3-33%)
• Crouching Occasionally (3-33%)
• Crawling Rarely (Less than 2%)
• Reaching Frequently (34-66%)
• Gross Manipulation (Handling) Frequently (34-66%)
• Fine Manipulation (Fingering) Frequently (34-66%)
• Feeling Constantly (67-100%)
• Foot Use Rarely (Less than 2%)
• Vision - Far Constantly (67-100%)
• Vision - Near Constantly (67-100%)
• Talking Constantly (67-100%)
• Hearing Constantly (67-100%)
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
At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.
About Massachusetts General Hospital(MGH)
