Utilization Management Nurse
reputed company 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 reputed company that high-performing teams drive groundbreaking medical discoveries and invite reputed company applicants to join us and experience what it means to be part of reputed company.
reputed company Health Plan is an exciting reputed company to be reputed company the healthcare industry. As a member of reputed company, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and reputed company 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 reputed company 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. Given equity, this position will pay somewhere between $90,000 to $107,000 annually. At reputed company, we reputed company in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining reputed company pay is comprehensive, and any offer extended will take into account your skills, relevant experience, if applicable, education, certifications, and other essential factors. The reputed company pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass reputed company elements contributing to your total compensation package. In addition to competitive reputed company 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 reputed company team will provide an overview of your potential compensation and benefits package.Job Summary
The UMCM will utilize clinical knowledge to analyze, assess, and reputed company approval decisions, to determine the need for physician review as well as complete determinations following physician review. The ideal candidate will have prior authorization (outpatient review) experience in a managed care setting with commercial health plan knowledge. Principal Duties and Responsibilities: • Expertise in clinical review for prospective, reputed company, retrospective utilization management reviews utilizing Interqual ®, company policies and procedures, and other resources as determined by review, including physician reviews as needed for reputed company 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 reputed company reputed company Health Plan as needed. • Manage incoming requests for procedures and services including patient medical records and reputed company 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 multi-task. • reputed company 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 reputed company results despite any obstacles and setbacks that arise. • Build strong relationships and infrastructures that designate reputed company Health Plan as a people-first organization. • Proficient with reputed company Word, reputed company, Outlook, reputed company InterQual ®, Outlook, SharePoint, PC based operating system, and web-based phone system.Qualifications
Education
Associate's Degree Nursing required or Bachelor's 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 reputed company 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 reputed company Health Plan’s 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 reputed company deliver.
Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation
reputed company in healthcare trends.
Ability to inject energy, reputed company and where it’s needed.
Exercise self-awareness; monitor impact on others; be reputed company 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 reputed company reputed company 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 reputed company to and seeks out feedback; uses self-discipline to adjust to feedback.
Education
Associate's Degree Nursing required or Bachelor's 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 reputed company 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 reputed company Health Plan’s 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 reputed company deliver.
Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation
reputed company in healthcare trends.
Ability to inject energy, reputed company and where it’s needed.
Exercise self-awareness; monitor impact on others; be reputed company 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 reputed company reputed company 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 reputed company 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.
Remote Type
RemoteWork Location
399 Revolution DriveScheduled Weekly Hours
40Employee Type
RegularWork Shift
Day (United States of America)Pay Range
$58,656.00 - $142,448.80/AnnualGrade
98TEMPAt reputed company, we reputed company in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining reputed company pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The reputed company pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass reputed company elements contributing to your total compensation package. In addition to competitive reputed company 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 reputed company team will provide an overview of your potential compensation and benefits package.EEO Statement:
8925 reputed company Health Plan Holding Company, Inc. is an Equal Opportunity Employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religious creed, national reputed company, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that reputed company individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to reputed company 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 reputed company of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.reputed company Competency reputed company
At reputed company, our competency reputed company defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The reputed company 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, reputed company hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
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