Utilization Review Nurse

Title: Nurse Reviewer, Utilization Management

Job Type: Full-time

Location: Hybrid — 4 days per week in Brighton, MA office; 1 day remote

FLSA Status: Exempt

About Us

BrightonOne is a nonprofit social enterprise delivering healthcare, housing, and hope to veterans and military-connected families, with enterprise discipline in service to those who served.

Position Overview

The Nurse Reviewer, Utilization Management performs prospective, concurrent, and retrospective medical necessity review of requested services to ensure members receive appropriate, high-quality care in the most suitable setting. Within a TRICARE Prime / USFHP framework, this role applies nationally recognized medical necessity criteria and TRICARE/DHA coverage requirements to authorization requests, coordinates with providers and internal teams, and escalates cases requiring physician-level judgment to senior clinical team members. Working within defined authorization authority, the Nurse Reviewer supports compliant, timely, and defensible utilization decisions that balance member advocacy with responsible stewardship of the benefit, and identifies members who would benefit from case management, care coordination, or behavioral health support.

Key Responsibilities

Medical Necessity Review

• Conduct prospective, concurrent, and retrospective reviews of requested services using InterQual and/or MCG criteria and applicable TRICARE/DHA coverage policy.
• Review prior authorization and referral requests for completeness and clinical appropriateness; approve within defined scope and route non-certifiable cases to the Medical Director with a clear clinical summary.
• As assigned, coordinate peer-to-peer discussions between requesting providers and the Medical Director and prepare case files supporting reconsiderations and appeals.
• Apply plan clinical policy consistently and document the criteria and rationale supporting each determination.
• Identify and refer potential quality-of-care concerns and potential fraud, waste, and abuse per protocol.

Concurrent Review & Discharge Coordination

• Perform inpatient concurrent review, monitor length of stay, and assess continued-stay medical necessity.
• Support discharge-planning coordination and timely transitions to the appropriate next level of care.

Care Coordination & Referral

• Identify members appropriate for case/care management, disease management, or behavioral health referral and coordinate warm handoffs.
• Recognize social and clinical risk factors that may affect care and route members to appropriate internal resources.
• Identify patterns of potential over- or under-utilization for individual members, such as repeat admissions, frequent ER visits, or recurring or duplicative requests, and refer them to case management or the Medical Director as appropriate.

Provider Collaboration & Timeliness

• Communicate with providers and facilities to obtain clinical information, clarify requests, and convey determinations in accordance with regulatory timeframes.
• Ensure all reviews meet DHA/TRICARE and accreditation turnaround-time requirements and notification standards.

Documentation & Compliance

• Maintain accurate, complete, and compliant review documentation within the UM platform.
• Support inter-rater reliability activities, internal audits, and DHA oversight and accreditation reviews (URAC).
• Maintain member confidentiality in compliance with HIPAA and organizational privacy policies.