Clinical Reviewer, Precertification RN

P32HS Point32Health Services Inc; Massachusetts; Hybrid; USD 90,000 - 134,000; Full time

Benefits offered by this job

Medical/Dental/Vision

Tuition program

Well-being benefits

Paid time off

Retirement plans

Job summary

Point32Health is seeking a Clinical Reviewer, Precertification RN, to manage complex caseloads and determine medical necessity and benefit coverage for members.

The role reports to Precertification Team Manager and requires independent work alongside a collaborative team, with strong clinical judgment and health plan knowledge.

Qualifications

• RN licensure in MA (current and unrestricted).
• Minimum of five years of clinical experience in utilization management, case management or quality assurance.
• Experience in a managed care setting preferred.

Responsibilities

• Performs utilization management to determine medical necessity and benefit coverage.
• Disposes coverage decisions within product-specific timeframes.
• Collaborates with Medical Directors on denial determinations and documents processes.

Skills

Registered Nurse

Utilization management

Case management

Quality assurance

Critical thinking

Communication

Education

Associate Degree

BSN preferred

Job description

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

The Clinical Reviewer, Precertification RN, is a licensed Registered Nurse that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for determining medical necessity and benefit coverage for Point32Health members. The Clinical Reviewer ensures consistent and timely disposition of coverage decisions as required by product specific compliance and regulatory time frames. The Clinical Reviewer functions as a member of the Precertification / Outpatient Utilization Management (UM) team and works under the general direction of the Precertification Team Manager or department Director. The Clinical Reviewer is expected to demonstrate the ability to work independently as well as collaboratively within a team environment. The Clinical Reviewer will be expected to demonstrate sound clinical and health plan business knowledge in their decision-making processes, on behalf of the health plan.

Job Description

Key Responsibilities/Duties – what you will be doing:

• Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames.
• Collaborates with Medical Directors when determination to deny a request is indicated, advising the Medical Directors on standard business processes, ensuring those processes are followed or variances to the process are escalated, if needed, and agreed to and well documented.
• Coaches letter writers to assure that appropriate medical necessity language is clearly defined in the denial letter.
• Communicates frequently through the day with physicians, practices, facilities, and/or allied health providers.
• Communicates frequently through the day with external customers (agents acting on behalf of the provider or member or both) regarding the rational for a determination, as well as the status and disposition of cases.
• Orients new staff to role as needed.
• Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.
• Facilitates communication between Precertification and other internal departments by acting as a liaison or committee member on the development or implementation of new programs.
• Provides input to the Medical Policy Department regarding the development of Medical Necessity Guidelines and adding input to purchased criteria through participation in the IMPAC medical systems.
• Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM processes.
• Assists in the screening of appeal cases to provide clinical input as needed or requested.
• Models professionalism and leadership in all capacities of the position to all audiences.
• Other projects and duties as assigned.

Qualifications – what you need to perform the job

• Certification and Licensure Registered Nurse with a current and unrestricted Massachusetts license required
• Education Required (minimum): Associate Degree
• Preferred: BSN (Bachelor of Science in Nursing)
• Experience Required (minimum): Five years’ clinical experience in utilization management, case management or quality assurance.
• Previous experience in a managed care setting.
• Preferred: Skill Requirements
• Requires an individual with highly developed critical thinking skills and the ability to investigate, evaluate and problem solve using sound clinical judgment and business knowledge.
• Requires the ability to work in an extremely complex and fast-paced production environment.
• Demonstrates skill in responding to inquiries from providers and/or members
• Must exhibit initiative and creativity in planning of work and be able to resolve cases correctly, effectively, expeditiously and within tight timeframes.
• Good organizational skills and a customer centered focus required.
• Individual must be able to use multiple software applications simultaneously.
• Excellent oral and written communication skills required.

Working Conditions and Additional Requirements

Fast paced business environment that requires prioritization and balancing of multiple demands. Continuous use of PC and telephone required. Ability to adjust work schedule on short notice to adapt to departmental, case driven needs. Must be able to work under normal office conditions and work from home as required. Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations. May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

$89,540.84 -$134,311.26

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law. Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

Equal opportunity

We welcome all All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.