RN Nurse Manager – Medicare & DSNP Utilization Management
Somerville, MA
PRIDE Health
5x8 hrs, Days
Referral Bonus

Job Title

RN Manager, Medicare and DSNP Utilization Management

Location

• Somerville, Massachusetts
• Remote position (Monday to Friday, 8:00 AM - 5:00 PM, no weekends or holidays)

Employment Details

• Full-time, Long-Term Assignment (approximately 13 weeks)
• 40 hours per week, Day shift

Job Summary

• Supervise and support a team of care coordinators and case managers to ensure adherence to clinical standards and protocols.
• Develop and implement strategies to improve clinical care coordination efficiency and effectiveness.
• Monitor patient care processes and outcomes for regulatory compliance.
• Facilitate collaboration among clinical teams, physicians, and other healthcare providers.
• Analyze patient data to identify trends and opportunities for intervention.
• Conduct performance evaluations and provide ongoing staff training and development.
• Manage caseload assignments, prioritizing based on patient acuity and resources.
• Oversee implementation of new care models or technologies to enhance patient care and operations.
• Ensure accurate documentation and reporting of case management activities and outcomes.

Required Qualifications

• Valid RN license in Massachusetts
• Bachelor of Science in Nursing
• 2 years of Utilization Review experience
• Utilization Review experience within the last year
• Experience in supervisory roles
• 2-3 years of Medicare and DSNP UM experience
• Long-Term Services and Supports (LTSS) experience
• Case Management experience

Required Credentials and Compliance

Health Requirements (Onboarding)

• Documentation of immunity or vaccination for Measles, Mumps, and Rubella (MMR)
• TB test documentation within 3 months of start date (skin test or blood test), updated if >6 month break
• Physician-signed health statement within 365 days of start date, updated if >6 month break

Background and Professional Checks (Onboarding)

• Criminal background check within 45 days prior to start, including county and international residence/employment history for past 7 years
• Massachusetts CORI background check within 30 days prior to start
• Social Security Number trace for past 7 years
• National sex offender registry check within 30 days prior to start, updated annually
• Exclusion checks against OIG, GSA, MassHealth, and NH Medicaid lists within 30 days prior to start, updated annually
• Education verification of highest degree achieved

Submission Requirements

• Resume including past 7 years of work experience with city and state
• Two professional references within 4 years, including at least one supervisor or higher
• Skills checklist completed within 1 year of submission
• Candidate submission coversheet (current version)

Additional Information

• Prior travel experience is not specified as required.
• No weekend or holiday shifts.
• Remote work with a primary location in Somerville, MA for administrative or occasional onsite needs.

This position is ideal for experienced RN leaders with strong clinical coordination and utilization management expertise, particularly in Medicare and DSNP programs, seeking a remote, full-time role with a focus on team leadership and process improvement.