UM Outpatient Clinical Review Nurse, Health England R40658

UM Outpatient Clinical Review Nurse – Baystate Health, Health New England

Full‑time remote position eligible for MA and CT residents. This role performs pre‑service, concurrent, and retrospective clinical utilization reviews for outpatient services, evaluating medical necessity and member health outcomes in accordance with regulations and internal policies.

• Perform pre‑service, concurrent, and retrospective reviews of member requests for outpatient care to determine health status, appropriateness of care, and documentation of findings.
• Collect, document, and maintain review findings and actions taken in the health management system per UM policies.
• Collaborate with providers to approve or deny requests based on evidence and policy.
• Coordinate with Medical Directors on denial determinations and provide education to providers on utilization processes.
• Assist in educating providers on utilization policies to ensure high‑quality, appropriate care for members.
• Collaborate with care management on member referrals when appropriate.
• Handle outpatient appeals and assist with appeals related to member and provider requests.
• Participate in weekend call program and flexible work hours as needed.
• Provide input to the Medical Policy Committee on policy development and updates.

• Current Massachusetts RN license.
• Bachelor’s degree (preferred) and 3‑5 years nursing experience.
• Knowledge of utilization management, Medicare, and Medicaid (strongly preferred).
• Critical thinking, clinical assessment, and decision‑making skills; experience in ICU, ER, or acute care highly valued.
• Proficiency with electronic health record systems and computer literacy.
• Excellent written and verbal communication, presentation skills, and time‑management abilities.
• Independent caseload management, teamwork, and collaboration.

• Competitive salary ($87,859 – $119,412 annually).
• Health, dental, and vision insurance.
• Generous paid time off and continuing education support.
• Well‑being programs and additional coverage (life, pet, auto, etc.).
• Reimbursement for gym and wellness activities.

Baystate Health is a regional not‑for‑profit health plan serving over 160,000 members in central and western Massachusetts and parts of Connecticut. The organization is committed to improving community health and providing growth opportunities for all employees.

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.