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Utilization Review Manager
Mass General BrighamUtilization Review Manager at Mass General Brigham managing care transitions and insurance audits post-discharge processes. Supporting effective collaboration across departments to ensure quality care and reimbursement.
Posted 7/14/2026part-timeRemote • Massachusetts • 🇺🇸 United StatesMid-LevelSenior💰 $41 - $100 per hourWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Review and Case Management, with a strong focus on evaluating care levels and managing clinical denials. Proficient in collaborating with healthcare professionals and understanding insurance criteria, particularly for Medicare and Medicaid.
Highest-signal resume keywords
Bachelor's Degree In NursingMassachusetts Registered Nurse LicenseAcute Care NursingUtilization ReviewCase Management
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ReviewAcute Care NursingClinical Denials ManagementQuality MonitoringDocumentation
Soft Skills
CollaborationCommunicationResourcefulness
Tools & Technologies
R.L. SolutionsExcelWord
Certifications & Qualifications
Registered Nurse License
Industry Keywords
MedicareMedicaidMillimanInterQualInsurance Plans
About the role
Key responsibilities & impact- Perform utilization review to evaluate for appropriate level of care
- Collaborate with appropriate individuals, departments, and payers to ensure appropriateness of admission and reimbursement
- Perform and monitor for quality issues and document in R.L. solutions
- Communicate with attending physician and care coordination nurse around denial of care
- Serve as a resource to staff and physicians about the process of denial of care for Medicare and other insurances
- Coordinate, complete, and track all clinical denials and appeals
Requirements
What you’ll need- Bachelor's Degree in Nursing required
- Massachusetts Registered Nurse License required
- 5 years of Acute Care Nursing required
- 3 years of Utilization Review and Case Management experience preferred
- 4 or more years of Utilization Review and Case Management experience preferred
- 6 or more years of Acute Care Nursing preferred
- Knowledge of different industry criteria sets like Milliman and InterQual
- In-depth understanding of all insurance plans, including Medicare, Medicaid
- Basic computer skills, experience with Excel and Word
Benefits
Comp & perks- Comprehensive benefits
- Career advancement opportunities
- Differentials, premiums, and bonuses as applicable
- Recognition programs designed to celebrate your contributions and support your professional growth