Utilization Management Nurse Reviewer

Job overview

The Utilization Management Nurse Reviewer role is hybrid, with four days per week in the Brighton, MA office and one day remote. Compensation is $95,000–$107,500 per year. BrightonOne is a nonprofit social enterprise delivering healthcare, housing, and support to veterans and military-connected families. The nurse reviewer evaluates requested services for medical necessity and appropriate care settings within a TRICARE Prime/USFHP framework. The role supports timely, compliant, and well-documented utilization decisions while coordinating with providers and referring members to additional support when appropriate.

What you'll do

• Conduct prospective, concurrent, and retrospective medical necessity reviews using InterQual and/or MCG criteria and applicable TRICARE/DHA policy. Review authorization and referral requests, approve within defined scope, and route non-certifiable cases to the Medical Director with a clinical summary. Perform inpatient concurrent review and discharge coordination
• identify members for case management, care coordination, disease management, or behavioral health referral. Communicate with providers, meet turnaround-time requirements, maintain compliant documentation, and support audits and accreditation reviews.

What we're looking for

Skills & competencies

utilization management nurse reviewer

brightonone

brighton ma

hybrid

tricare

usfhp

medical necessity review

interqual

mcg criteria

rn license

provider collaboration

care coordination

$95,000–$107,500 per year

veteran and military-family services

Work arrangement

• Weekend coverage required

Why this role

Requires an active, unrestricted Massachusetts RN license, an associate degree in nursing, clinical nursing experience, and utilization management or review experience. A government personnel security clearance must be obtained and maintained.

About the employer

BrightonONE is hiring for this role. Industry: Home Health Care Services. Sector: 62.