Utilization Management Nurse, Escalation Support

Mass General Brigham Assembly Square, MA 02145, US

Site: Mass General Brigham Health Plan Holding Company, Inc.

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 $90,000 to $107,000 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 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 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.

Provides clinical review and escalation support for Utilization Management (UM) activities by triaging inquiries, calls, ticket submissions, and external requests- evaluating medical necessity, appropriateness of care, and compliance with regulatory and organizational guidelines. Collaborates with Nurse Reviewers, Medical Directors, providers, and interdisciplinary teams to address complex cases, facilitate timely determinations, and ensure accurate application of evidence-based criteria to appropriately answer and respond to provider, member, and interdisciplinary needs. Serves as a clinical resource for escalated authorizations, appeals, and coverage determinations while promoting quality outcomes, regulatory compliance, and member-centered care.

Essential Functions

-Serves as the primary point of contact for escalated utilization management inquiries, ensuring timely triage, assessment, and resolution of complex provider, member, and internal stakeholder requests.
-Reviews and responds to escalated authorization, coverage determination, and service-related issues, coordinating with Nurse Reviewers, Medical Directors, and operational teams to facilitate appropriate next steps and ensure regulatory compliance.
-Monitors escalation channels, including phone calls, shared inboxes, ticketing systems, and other referral pathways, prioritizing requests based on clinical urgency, regulatory requirements, and business impact.
-Provides consultation and clinical guidance to utilization management staff regarding benefit interpretation, medical necessity criteria, workflow processes, and resolution of complex or sensitive cases.
-Identifies trends, recurring issues, and process improvement opportunities through escalation review activities, collaborating with leadership and cross-functional partners to enhance operational efficiency, provider experience, and member outcomes.

Qualifications

Education

Associate's Degree Nursing required or Bachelor's Degree Nursing preferred

Licenses and Credentials

Massachusetts Registered Nurse (RN) license
Basic Life Support (BLS) Certification preferred

Experience

At least 2-3 years of case management, utilization review, or discharge planning experience preferred

Knowledge, Skills, and Abilities

Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
Ability to establish strong rapport and relationships with patients and staff.
Proficient in Microsoft Office and industry-related software programs.
Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
Ability to maintain client and staff confidentiality.
Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
Knowledge of Healthcare and Managed Care preferred.

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

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

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.

EEO Statement:

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 Veteran’s 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 (857)-282-7642.

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.

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Provides telephone triage according to policies and documents telephone interactions. Performs the following technical skills; Intravenous therapy including peripheral and central venous vascular access devices, including obtaining IV access, Safe handling practices for hazardous, cytotoxic and biological agents, Chemotherapy administration skills, including vesicant and non-vesicant medications. Complies with accepted standards of professional nursing practice, as well as with all licensure/registration requirements applicable to the nursing role. Supports the DFCI Nursing Department Professional Practice Model and Quality Plan. Accurately records charges for all services rendered on the day service. Collaborates with Clinic Assistant to assure accurate inventory of all supplies. Serves as a resource to medical personnel in other health facilities, providing telephone consultation to engender optimal Oncology practices and knowledge among health care professionals caring for cancer patients. Establishes rapport with patients and families from a variety of cultural, ethnic and religious backgrounds: Interacts with patients and families in a caring and compassionate manner respecting the need for privacy and confidentiality. Develops approaches to problem solving which meet the individual needs of the patients and families. Demonstrates the knowledge and skills necessary to provide age-specific care and support to the populations served. Promotes a culture of inclusion. Fosters an environment that is sensitive to the needs of diverse populations, including but not limited to culture, ethnicity, gender, and age. Manages the environment of patient care: Monitors the environment of care with attention to patient safety and assures compliance with regulatory agency standards. Complies with applicable policies, procedures, work rules and standards of conduct. Adheres to the Code of Ethics for Nurses with Interpretive Statements (ANA, 2015) in all aspects of professional practice. Bases care on the Standards of Oncology Nursing Practice and Oncology Nursing Society Chemotherapy Guidelines. Works collaboratively and functions as an effective member of the health care team: Demonstrates the ability to work collaboratively with peers and co-workers. Effectively addresses and manages conflicts. Demonstrates excellent communication skills. Demonstrates effectiveness as a contributing member to the multidisciplinary health care team. Delegates as appropriate and supervises assistive personnel in their provision of patient care. May function in the charge nurse role when necessary, collaborating with staff and coordinating flow of patients into the infusion areas. Participates in committees, councils, and initiatives. Demonstrates flexibility in setting and changing priorities. Accepts additional responsibilities as needed. Participates in QA/QI projects for the unit as requested. Seeks opportunities to foster professional growth: Identifies areas for professional growth. Formulates professional goals, objectives and methods for accomplishing these. Attends in-services, workshops and seminars. Shares information gained with colleagues. Facilitates professional growth of self and others by acting as a preceptor and mentor for new staff. Meets all annual evaluation requirements and competencies within the established time period. Pursues active membership in local and national professional organizations. Knowledge, Skills, And Abilities Required Demonstrated ability to work as an effective member of an interdisciplinary team Demonstrated skills in critical thinking, problem solving, and ability to make independent decisions Ability to function in a busy work setting with patients with complex needs IV skills strongly preferred Work tasks require walking, standing, climbing, sitting, bending, reaching and occasional lifting. Some tasks are performed while sitting Good hearing and vision are required for the time spent in interactions with others, telecommunications and the required reading of medical and pharmaceutical documents and patient care related documents Communications with physicians or staff during office hours requires organization of information, discretion and balancing of multiple communications Relationships with patients/families and colleagues requires excellent listening skills, the ability to identify issues and seek a resolution that reflects the quality care and satisfaction goals of the practice The work requires concentration and frequent mental and visual attention as well as the ability to work efficiently. Frequent interruptions and movement away from desk require the ability to stay focused and return to uncompleted tasks Telephone communications listening and speaking skills are required for the time spent in this mode of communication The ability to balance multiple tasks and normal stress associated with the duties and responsibilities of this position are essential requirements in the performance of this job The ability to speak, read and write in English, and the ability to perform mathematical pharmaceutical calculations is required for this position Demonstrates understanding of special needs and behaviors of age groups of the population served: young adult to geriatric Minimum Job Qualifications The position requires licensure as a Registered Nurse in the Commonwealth of Massachusetts or New Hampshire, as appropriate. A bachelor’s degree in nursing is strongly preferred, and candidates with an associate degree must complete a BSN within 4 years. At least 1 year of recent RN experience is required, with ambulatory and/or oncology experience preferred. Professional nursing certification (e.g., OCN, BMTCN, CPHON, AOCNP, CRNI, RN-BC) is preferred, and AHA BLS certification is required (AHA ACLS is acceptable as a minimum requirement). Supervisory Responsibilities No direct supervision of others but does supervise assistive personnel as appropriate in the provision of patient care. PATIENT CONTACT: Yes At Dana-Farber Cancer Institute, we work every day to create an innovative, caring, and inclusive environment where every patient, family, and staff member feels they belong. As relentless as we are in our mission to reduce the burden of cancer for all, we are committed to having faculty and staff who offer multifaceted experiences. Cancer knows no boundaries and when it comes to hiring the most dedicated and compassionate professionals, neither do we. If working in this kind of organization inspires you, we encourage you to apply. Dana-Farber Cancer Institute is an equal opportunity employer and affirms the right of every qualified applicant to receive consideration for employment without regard to race, color, religion, sex, gender identity or expression, national origin, sexual orientation, genetic information, disability, age, ancestry, military service, protected veteran status, or other characteristics protected by law. EEO Poster Pay Transparency Statement The hiring range is based on market pay structures, with individual salaries determined by factors such as business needs, market conditions, internal equity, and based on the candidate’s relevant experience, skills and qualifications. For union positions, the pay range is determined by the Collective Bargaining Agreement (CBA). $82,367.58 - $124,614.60

Med-Surg

Full-time

1 week ago

Registered Nurse, Med Surg, Evenings, 32 hours

UMass Memorial Health Marlborough, MA

Are you a current UMass Memorial Health caregiver? Apply now through Workday. Exemption Status: Non-Exempt Hiring Range: $38.65 - $78.34 Please note that the final offer may vary within this range based on a candidate’s experience, skills, qualifications, and internal equity considerations . Schedule Details: Holidays - Every Other Holiday, Sunday through Saturday, Weekends - Every Other Weekend Scheduled Hours: 1445-2315 Shift: 2 - Evening Shift, 8 Hours (United States of America) Hours: 32 Cost Center: 21000 - 0226 Nursing 2 Union: MNA-Marlborough (Massachusetts Nurses Association) This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process. Everyone Is a Caregiver At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day. Responsible for the planning, delivery and management of direct patient care utilizing the nursing process and adhering to the standards of nursing practice. I. Major Responsibilities: 1. Utilizes the Nursing Process for the delivery and management of patient’s care from Admission to Discharge, appropriate to the developmental age of the patient population. 2. Performs patient assessment/reassessment according to standard procedure. 3. Develops and coordinates individual plan of care including discharge planning. 4. Directs, supervises, coordinates and evaluate nursing care within assigned clinical setting. 5. Delegates appropriately to others in accordance with job description and competency level. II. Position Qualifications: License/Certification/Education: Required: 1. Current Massachusetts Nursing licensure and registration. 2. BLS is a requirement for every RN unless advance cardiac life support (ACLS) certification is current, in addition to any unit specific certifications and competencies. Preferred : 1. Bachelor of Science degree in Nursing highly preferred. Experience/Skills: Required: 1. Thorough knowledge of the discipline of Nursing. Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements. Department-specific competencies and their measurements will be developed and maintained in the individual departments. The competencies will be maintained and attached to the departmental job description. Responsible managers will review competencies with position incumbents. III. Physical Demands and Environmental Conditions: Work is considered medium. Position requires work indoors in a patient care environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. We’re striving to make respect a part of everything we do at UMass Memorial Health – for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day. As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law. If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at talentacquisition@umassmemorial.org. We will make every effort to respond to your request for disability assistance as soon as possible.