Utilization Management Nurse
About this role
Description
Title: Nurse Reviewer, Utilization Management
Job Type: Full-time
Location: Hybrid — 4 days per week in Brighton, MA office; 1 day remote
FLSA Status: Exempt
About Us
BrightonOne is a nonprofit social enterprise delivering healthcare, housing, and hope to veterans and military-connected families, with enterprise discipline in service to those who served.
Position Overview
The Nurse Reviewer, Utilization Management performs prospective, concurrent, and retrospective medical necessity review of requested services to ensure members receive appropriate, high-quality care in the most suitable setting. Within a TRICARE Prime / USFHP framework, this role applies nationally recognized medical necessity criteria and TRICARE/DHA coverage requirements to authorization requests, coordinates with providers and internal teams, and escalates cases requiring physician-level judgment to senior clinical team members. Working within defined authorization authority, the Nurse Reviewer supports compliant, timely, and defensible utilization decisions that balance member advocacy with responsible stewardship of the benefit, and identifies members who would benefit from case management, care coordination, or behavioral health support.
Key Responsibilities
Medical Necessity Review
• Conduct prospective, concurrent, and retrospective reviews of requested services using InterQual and/or MCG criteria and applicable TRICARE/DHA coverage policy. • Review prior authorization and referral requests for completeness and clinical appropriateness; approve within defined scope and route non-certifiable cases to the Medical Director with a clear clinical summary. • As assigned, coordinate peer-to-peer discussions between requesting providers and the Medical Director and prepare case files supporting reconsiderations and appeals. • Apply plan clinical policy consistently and document the criteria and rationale supporting each determination. • Identify and refer potential quality-of-care concerns and potential fraud, waste, and abuse per protocol.
Concurrent Review & Discharge Coordination
• Perform inpatient concurrent review, monitor length of stay, and assess continued-stay medical necessity. • Support discharge-planning coordination and timely transitions to the appropriate next level of care.