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Remote Insurance Utilization Review Jobs in Massachusetts

Sentara

IT Specialty Analyst (Epic) - Remote

MA · Remote

... for optimal utilization of applications. Develops system test plans and performs testing of ... Life Insurance 401k/403B with Employer Match Tuition Assistance - 5,250/year and discounted ...

Sentara

IT Specialty Analyst (Epic) - Remote

MA · Remote

... for optimal utilization of applications. Develops system test plans and performs testing of ... Life Insurance 401k/403B with Employer Match Tuition Assistance - 5,250/year and discounted ...

Beacon Talent

Remote Psychiatrist

Worcester, MA · Remote

$150 - $200/hr

... making rather than scheduling, insurance verification, or chasing records. Clinical ... Document within our behavioral health EMR to the standard required for payer review * Escalate ...

Posted today

Beacon Talent

Remote Psychiatrist

Boston, MA · Remote

$150 - $200/hr

... making rather than scheduling, insurance verification, or chasing records. Clinical ... Document within our behavioral health EMR to the standard required for payer review * Escalate ...

Posted today

Beacon Talent

Remote Psychiatrist

Littleton, MA · Remote

$150 - $200/hr

... making rather than scheduling, insurance verification, or chasing records. Clinical ... Document within our behavioral health EMR to the standard required for payer review * Escalate ...

Posted today

Cytel

Associate Director, Project Finance

Cambridge, MA · On-site +1

This remote role requires someone who can operate autonomously, influence without authority, and ... Prepare executive-level reporting and presentations for leadership review. * Translate complex ...

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Showing results 21-40

All JobsInsurance Utilization Review JobsRemote Insurance Utilization Review JobsRemote Insurance Utilization Review Jobs in Massachusetts

Remote Insurance Utilization Review information

What is the difference between Remote Insurance Utilization Review vs Remote Claims Reviewer?

AspectRemote Insurance Utilization ReviewRemote Claims Reviewer
CredentialsTypically requires nursing or healthcare-related certifications, such as RN or licensed healthcare professionalUsually requires insurance or claims processing knowledge, sometimes with certifications like CPC or CPC-H
Work EnvironmentRemote, healthcare or insurance company settings, reviewing medical necessity and appropriateness of servicesRemote, insurance companies or third-party administrators, reviewing claims for accuracy and compliance
Industry UsageCommonly used in healthcare insurance to evaluate medical necessityUsed across insurance sectors to process and validate claims

Remote Insurance Utilization Review focuses on assessing the medical necessity of services, often requiring healthcare credentials. Remote Claims Reviewers handle claims processing and validation, emphasizing insurance knowledge. Both roles are remote and industry-specific but differ in their primary responsibilities and required qualifications.

How does a remote insurance utilization review professional collaborate with healthcare providers and insurance companies?

Remote insurance utilization review professionals regularly interact with healthcare providers to gather patient information, clarify treatment plans, and ensure that clinical documentation supports insurance requirements. They also communicate with insurance companies to advocate for patient care, provide necessary justifications, and resolve coverage issues. While the work is done remotely, collaboration typically occurs via secure email, phone calls, and virtual meetings, requiring strong communication and organizational skills to ensure timely and accurate exchange of information.

What is a remote insurance utilization review?

Remote insurance utilization review jobs involve evaluating medical records and treatment plans to determine whether healthcare services are medically necessary and covered by a patient’s insurance plan. Professionals in these roles, often nurses or other healthcare specialists, work from home and communicate with healthcare providers, insurance companies, and patients. Their main goal is to ensure that patients receive appropriate care while also helping insurance companies manage costs and comply with regulations.

What skills and qualifications are needed for a remote insurance utilization review specialist?

To thrive as a Remote Insurance Utilization Review Specialist, you need a strong understanding of medical terminology, clinical guidelines, and insurance policies—usually supported by a nursing or health-related degree and relevant licensure. Familiarity with electronic medical record (EMR) systems, insurance claims platforms, and utilization review software is essential. Strong analytical skills, attention to detail, and effective written communication are crucial soft skills for this role. These competencies ensure accurate case evaluations, compliance with regulations, and clear communication between healthcare providers and insurers.

What are popular job titles related to Remote Insurance Utilization Review jobs in Massachusetts?

For Remote Insurance Utilization Review jobs in Massachusetts, the most frequently searched job titles are:

What job categories do people searching Remote Insurance Utilization Review jobs in Massachusetts look for?

The top searched job categories for Remote Insurance Utilization Review jobs in Massachusetts are:

What cities in Massachusetts are hiring for Remote Insurance Utilization Review jobs?

Cities in Massachusetts with the most Remote Insurance Utilization Review job openings:

Remote Insurance Utilization Review jobs near you
Infographic showing various Remote Insurance Utilization Review job openings in Massachusetts as of August 2026, with employment types broken down into 89% Full Time, 7% Part Time, and 4% Contract. Highlights an 100% Remote job distribution.

Senior Medical Director, Health Plan

Massgeneralbrigham

Somerville, MA • Remote

Full-time

Posted 9 days ago

Job description

Site: Mass General Brigham Health Plan Holding Company, Inc.


Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.


Job Summary

The Senior Medical Director serves as a key clinical executive within the health plan, providing strategic leadership, medical oversight, and clinical expertise to ensure highquality, costeffective care for members. This role partners closely with executive leadership, clinical operations, network management, quality, and compliance teams to shape clinical strategy, guide utilization management, and support valuebased care initiatives. The Senior Medical Director represents the health plan externally with providers, regulators, and community partners.
Does this position require Patient Care?
Yes


Qualifications

Essential Function:

  • Develop and execute clinical strategies that improve member outcomes, reduce unnecessary utilization, and support organizational goals and provide medical expertise to guide benefit design, population health programs, and valuebased care models.
  • Serve as a clinical advisor to senior executives and crossfunctional teams.
  • Oversee utilization management (UM) programs, ensuring evidencebased, timely, and compliant decisionmaking.
  • Review complex or escalated cases, appeals, and grievances, and ensure UM policies align with regulatory requirements, accreditation standards, and clinical best practices.
  • Lead quality improvement initiatives, including HEDIS, Stars, NCQA, and other performance programs, and partner with analytics teams to identify trends in utilization, quality, and member health outcomes.
  • Support the development of population health programs targeting chronic disease management, behavioral health, and social determinants of health.
  • Collaborate with provider network teams to improve clinical performance, reduce variation, and support valuebased contracting, and engage with physicians and health systems to promote evidencebased care and address performance issues.
  • Represent the health plan in provider forums, committees, and external meetings.
  • Ensure clinical programs comply with federal and state regulations, accreditation standards, and internal policies, and participate in audits, regulatory reviews, and accreditation activities.
  • Maintain uptodate knowledge of evolving healthcare regulations and clinical guidelines.
  • Partner with behavioral health, pharmacy, care management, and social care teams to coordinate integrated care strategies.
  • Provide medical leadership for product development, member engagement initiatives, and clinical innovation projects, and support executive leadership with clinical insights for strategic planning and organizational decisionmaking.

Education:
Doctorate Related Field of Study required
Can this role accept experience in lieu of a degree?
No
Licenses and Credentials
Physician License. Must hold or be able to obtain a full active Massachusetts physician license.

Must have 3-5 years of Health Plan experience

  • Must have prior experience in utilization management, peer to peer discussions


Experience:
Clinical Experience 8-10+ years required and Experience in managed care, health plan, or population health leadership role 5-7 years required
Knowledge, Skills and Abilities:

  • Strategic thinking and clinical judgment
  • Executive communication and influence
  • Datadriven decisionmaking
  • Collaborative leadership
  • Regulatory and compliance awareness
  • Provider engagement and relationshipbuilding

Salary Range:

$320 - $350K (depending upon experience)


Additional Job Details (if applicable)


Remote Type

Remote


Work Location

399 Revolution Drive


Scheduled Weekly Hours

40


Employee Type

Regular


Work Shift

Day (United States of America)


EEO Statement:

8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.


Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

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