Hybrid Nurse Manager, Utilization Review, Clinical Appeal Management

at Boston Medical Center (BMC)

• Job title: Nurse Manager, Utilization Review, Clinical Appeal Management
• Job type: Full Time
• Experience level: Mid level, Senior
• Salary: $72,500 - $105,000 per year
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, Boston, United States

About the role

• Nurse Manager for Utilization Review and Clinical Appeal Management at Boston Medical Center. Overseeing operations and compliance while leading training and quality initiatives in healthcare.

Responsibilities

• Overseeing the daily operations of the Utilization Management (UM) and Clinical Appeal teams
• Ensuring compliance with hospital policies, regulatory requirements, and payer guidelines
• Supporting efficient and effective utilization review and denial management processes
• Leadership, staff training, and quality improvement initiatives
• Collaborating with interdisciplinary teams to reduce payer denials
• Approving timekeeping and schedule changes in Kronos
• Providing comprehensive training for new staff and ongoing educational support for existing team members
• Conducting performance improvement audits

Requirements

• Nursing degree: Diploma, ASN or BSN (preferred)
• Ability to obtain BSN within 4 years
• Master’s Degree in Nursing or healthcare related field preferred
• Licensed to practice as a Registered Nurse in Massachusetts required
• CCM or related certification attained within 24 months from hire date preferred
• Minimum of 5 years of inpatient clinical nursing experience
• Minimum of 3 years of utilization review and denials management experience
• Epic and InterQual experience required
• ACM-RN or CCM preferred
• UKG Payroll experience preferred
• Experience working with vulnerable patient populations
• Clinical experience working with patients with multiple complex health issues
• Progressive leadership experience

Benefits

• Medical, dental, and vision insurance
• Discretionary annual bonuses and merit increases
• Flexible Spending Accounts
• 403(b) savings matches
• Paid time off
• Career advancement opportunities
• Resources to support employee and family well-being