Massachusetts RN licenseMassachusetts Registered Nurse (RN) licenseCheck your license
Education
Associate's degree in nursingAssociate's Degree Nursing required
Also asks
Proficient in Microsoft Office and industry softwareProficient in Microsoft Office and industry-related software programs.
Also asks
Understanding of dual-condition diagnostic criteria and placement within the continuum of careUnderstanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
Preferred
Certification
BLS certificationBasic Life Support (BLS) Certification preferred
Education
Bachelor's degree in nursingAssociate's Degree Nursing required or Bachelor's Degree Nursing preferred
Experience
2-3 years of case management, utilization review or discharge planningAt least 2-3 years of case management, utilization review, or discharge planning experience preferred
Also asks
Knowledge of healthcare and managed careKnowledge of Healthcare and Managed Care preferred.
What it pays
Against similar roles
Massachusetts staff median is $111k/yrMassachusetts staff postings that state pay run $68k/yr to $153k/yr, the middle half $86k/yr to $141k/yr, across 1,478 postings. This posting's $59k/yr to $142k/yr is wider than that, so where you land depends on the offer.
Pay reviews
Offer depends on your skills, relevant experience, education and certificationsany offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors
BenefitsFlexible work optionsWe are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.
BenefitsCareer growth and advancement opportunitiescareer advancement opportunities
Competitive salaries
Benefits package
Career growth opportunities
The role and schedule
Day to day
Review and respond to escalated authorization, coverage determination and service issuesReviews and responds to escalated authorization, coverage determination, and service-related issues
Day to day
Clinical resource on escalated authorizations, appeals and coverage determinationsServes as a clinical resource for escalated authorizations, appeals, and coverage determinations
Day to day
Give clinical guidance to UM staff on benefit interpretation and medical necessity
Day to day
Work with Nurse Reviewers and Medical Directors to move complex cases to timely determinationsCollaborates with Nurse Reviewers, Medical Directors, providers, and interdisciplinary teams to address complex cases, facilitate timely determinations
Day to day
Spot trends and recurring issues in escalations and propose process fixesIdentifies trends, recurring issues, and process improvement opportunities through escalation review activities
On call
On call at least once a month, possibly more depending on staff availability, starting about 6 months after hireWould 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.
Details
Remote, with occasional onsite team meetings in SomervilleThis is a remote role with occasional onsite team meetings in Somerville, MA.
The workplace
MG
Mass General Brigham Health Plan Holding Company, Inc.
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.
Neighborhoods+Assembly Square offers modern, high-amenity residential complexes and elevator buildings right on the Mystic River. Davis Square provides classic Somerville energy centered on independent cafes, historic nightlife, and Red Line transit. Union Square blends historic multi-family homes with fast-growing contemporary development surrounding the Green Line Extension, while Ball Square, East Somerville, and Winter Hill offer traditional triple-decker residential character with rich immigrant businesses.
Assembly Square offers modern, high-amenity residential complexes and elevator buildings right on the Mystic River. Davis Square provides classic Somerville energy centered on independent cafes, historic nightlife, and Red Line transit.
Union Square blends historic multi-family homes with fast-growing contemporary development surrounding the Green Line Extension, while Ball Square, East Somerville, and Winter Hill offer traditional triple-decker residential character with rich immigrant businesses.
Getting around+Somerville provides direct transit into Cambridge, downtown Boston, and connections toward the Longwood Medical Area via the MBTA Red Line at Davis Square, the Orange Line at Assembly, and Green Line Extension branches through Union Square and Medford. The city is crisscrossed by MBTA bus routes with dedicated transit lanes, and drivers access regional routes via Interstate 93. However, resident street parking on narrow residential roads is notoriously tight, making driving a frequent logistical challenge.
Somerville provides direct transit into Cambridge, downtown Boston, and connections toward the Longwood Medical Area via the MBTA Red Line at Davis Square, the Orange Line at Assembly, and Green Line Extension branches through Union Square and Medford. The city is crisscrossed by MBTA bus routes with dedicated transit lanes, and drivers access regional routes via Interstate 93. However, resident street parking on narrow residential roads is notoriously tight, making driving a frequent logistical challenge.
Outdoors+Outdoor recreation is anchored by the Somerville Community Path, a paved trail linking Davis Square with neighboring Cambridge and downtown transit routes for car-free walking and cycling. Prospect Hill Park features panoramic views of the Boston skyline and historic Revolutionary War grounds, while Powderhouse Park offers quieter green space. To the northeast, the Mystic River Reservation provides open-air riverfront paths, parklands, and water access for kayaking.
Outdoor recreation is anchored by the Somerville Community Path, a paved trail linking Davis Square with neighboring Cambridge and downtown transit routes for car-free walking and cycling. Prospect Hill Park features panoramic views of the Boston skyline and historic Revolutionary War grounds, while Powderhouse Park offers quieter green space.
To the northeast, the Mystic River Reservation provides open-air riverfront paths, parklands, and water access for kayaking.
Somerville offers healthcare professionals a high-density, culturally vibrant base immediately adjacent to Boston and Cambridge. Defined by its animated commercial squares—including Davis Square's indie music and historic Somerville Theatre, Union Square's inventive culinary enclave at Bow Market, and the modern waterfront towers of Assembly Row—the city provides exceptional urban walkability across just four square miles. Hospital commutes are anchored by the MBTA Red Line, Orange Line, and the Green Line Extension, making transit into downtown facilities, Kendall Square, or the Longwood area straightforward without relying on a car. The Somerville Community Path provides a seamless off-road connection for cycling and running. The primary tradeoffs stem from density and aging infrastructure: housing is dominated by classic wooden triple-deckers with narrow staircases, street parking requires constant vigilance, and winter snow regulations test car owners. However, for nurses who value an artistic community renowned for events like Porchfest, global dining, and top-tier transit access, Somerville is an exceptionally rewarding relocation destination.
