Utilization Review Nurse

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.

Care Coordination & Referral

• Identify members appropriate for case/care management, disease management, or behavioral health referral and coordinate warm handoffs.
• Recognize social and clinical risk factors that may affect care and route members to appropriate internal resources.
• Identify patterns of potential over- or under-utilization for individual members, such as repeat admissions, frequent ER visits, or recurring or duplicative requests, and refer them to case management or the Medical Director as appropriate.

Provider Collaboration & Timeliness

• Communicate with providers and facilities to obtain clinical information, clarify requests, and convey determinations in accordance with regulatory timeframes.
• Ensure all reviews meet DHA/TRICARE and accreditation turnaround-time requirements and notification standards.

Documentation & Compliance

• Maintain accurate, complete, and compliant review documentation within the UM platform.
• Support inter-rater reliability activities, internal audits, and DHA oversight and accreditation reviews (URAC).
• Maintain member confidentiality in compliance with HIPAA and organizational privacy policies.

Requirements

Qualifications

Education & Experience

• Associate’s degree in Nursing (ADN/RN) required; Bachelor's degree in Nursing (BSN) preferred.
• 2 or more years of clinical nursing experience.
• 1 or more years of utilization management, utilization review, or medical necessity review experience in a managed care or health plan setting.
• Experience reviewing Applied Behavior Analysis (ABA) services, or with TRICARE’s Extended Care Health Option (ECHO) program, is a plus but not required.
• Experience applying InterQual and/or MCG criteria.

Licensure & Certifications

• Active, unrestricted RN license in Massachusetts.
• Certified Case Manager (CCM), Health Care Quality and Management (HCQM), or other utilization management certification preferred.

Skills & Competencies

• Working knowledge of medical necessity criteria and UM review methodology across prospective, concurrent, and retrospective review.
• Willingness and ability to learn the TRICARE benefit structure, coverage policy, and appeals process; prior TRICARE experience is a plus but not required.
• Strong clinical assessment, critical thinking, problem-solving, and decision-making abilities.
• Ability to exercise sound independent judgment within defined authorization authority and recognize when to escalate for physician review.
• Knowledge of regulatory turnaround-time requirements and UM compliance standards, with the ability to manage a review queue and prioritize effectively under time constraints.
• High attention to detail and strong documentation discipline.
• Outstanding written and verbal communication skills, including the ability to write clear clinical summaries and explain determinations to providers.
• Proficiency with electronic medical records, utilization review systems, and MS Office Suite.
• Ability to work collaboratively across departments and with external partners.
• High level of discretion, professionalism, and commitment to patient confidentiality.
• Experience within a TRICARE, USFHP, Medicare Advantage, or Medicaid managed care organization is a plus but not required.
• Familiarity with URAC utilization management standards and electronic UM platforms is a plus but not required.
• Familiarity with military culture and the unique needs of veterans and military-connected families is a plus but not required.

Other Requirements

• Must be able to obtain and maintain U.S. Government personnel security clearance as a condition of employment.

Physical Nature of the Job

Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move throughout the campus.

Equal Opportunity Employer Statement

BrightonOne is an Equal Opportunity Employer. We prohibit discrimination and harassment of any kind based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, protected veteran status, or any other characteristic protected by federal, state, or local law. We strongly encourage applications from veterans and individuals with disabilities. Accommodations are available upon request for candidates taking part in all aspects of the selection process.

Work Authorization

Candidates must be authorized to work in the United States without sponsorship now or in the future.