Utilization Management Nurse

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