SCO RN UM Reviewer

Thank you for your interest in a career at NeighborHealth, formerly East Boston Neighborhood Health Center!

As one of the largest community health centers in the country, NeighborHealth is proud to serve the greater Boston area with a strong commitment to the health and well-being of our patients and communities.

Whether you're a nurse or physician providing direct care, a manager leading dedicated teams, or part of the essential support staff who keep our operations running smoothly — every role at NeighborHealth is vital.

Together, we’re advancing medicine and delivering the best care experience for our patients and community!

Interested in this position? Apply online and create a personal candidate account!

Current Employees of NeighborHealth- Please use our internal careers portal to apply for positions.

To learn more about working at NeighborHealth and our benefits, please visit out our Careers Page.

Time Type:
Full time

Department:
Senior Care Options (SCO)

All Locations:
10 Gove Street – Taylor Building

Position Summary:
What You'll Do

The Utilization Management (UM) Reviewer RN is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making.

The Utilization Management Review Nurse has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations.

This position requires universal skills and proficiencies which include demonstrating a comprehensive understanding of the Health Center’s mission and core values--compassion, diversity, innovation, respect.

In addition, the SCO RN UM Reviewer initiative, critical thinking, problem solving, leadership qualities, and effectively engages with the clinical team.

What You'll Do

The Utilization Management (UM) Reviewer RN is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making.

The Utilization Management Review Nurse has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations.

This position requires universal skills and proficiencies which include demonstrating a comprehensive understanding of the Health Center’s mission and core values--compassion, diversity, innovation, respect.

In addition, the SCO RN UM Reviewer initiative, critical thinking, problem solving, leadership qualities, and effectively engages with the clinical team.

The successful candidate will be able to perform the following responsibilities:


* Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements


* Meet or exceeds Timely authorizations


* Provides decision-making guidance to clinical teams on service planning as needed.


* Works closely with RN Case managers & Me...