Massachusetts Licensed Utilization Management RN

Job Summary

To support members receiving Long Term Services and Supports, the full-time Massachusetts Licensed Utilization Management RN will manage clinical determinations, authorization support, and appeals in a hybrid role that is approximately 75% remote and 25% onsite for meetings and training.

Key responsibilities

• Synthesize assessment data and documentation to evaluate members' clinical and functional status against care criteria
• Develop clinical determinations and written rationales for service requests and annual redeterminations, ensuring compliance with regulations
• Manage the appeals process, including assembling submissions and preparing materials for hearings, while collaborating with care teams and external agencies

Required qualifications

• Active, unrestricted Registered Nurse (RN) license in Massachusetts
• Graduate of an accredited school of nursing
• 3 or more years of clinical experience, preferably in utilization management or medical necessity determination
• Familiarity with long term services and supports and functional assessment instruments
• Understanding of MassHealth LTSS coverage criteria and Medicaid/Medicare authorization processes