Clinical Reviewer, Precertification RN

Point32Health, Inc.; Massachusetts; Sur place; USD 90 000 - 134 000; Plein temps

Avantages offerts par ce poste

Medical coverage

Dental coverage

Vision coverage

Retirement plans

Paid time off

Life and disability insurance

Tuition program

Well-being benefits

Résumé du poste

Point32Health is seeking a Clinical Reviewer, Precertification RN to manage a clinically complex caseload and support utilization management and medical necessity determinations. The role emphasizes independent and collaborative work within a team while applying sound clinical knowledge.

The position offers remote work with MA licensure and a strong benefits package, targeting experienced RNs in utilization management and related fields.

Qualifications

• Five years' clinical experience in utilization management, case management, or quality assurance.
• Massachusetts RN license required (unrestricted).]
• job_responsibilities_description:[
• Provide clinical decision making and support for utilization management, medical necessity determinations, and benefit determinations.
• Collaborate with Medical Directors on denial requests and ensure adherence to business processes.
• Coach letter writers to ensure appropriate medical necessity language in denial letters.
• Communicate frequently with physicians, practices, facilities, and allied health providers.
• Interface between Precertification staff and providers regarding policy interpretation and quality assurance issues.
• Facilitate communication between Precertification and other internal departments.
• Provide input to the Medical Policy Department on Medical Necessity Guidelines.
• Proactively identify trends in Utilization Management.
• Assist in screening appeal cases for clinical input.
• Model professionalism and leadership in all capacities of the position.

Responsabilités

• Provide clinical decision making and support for utilization management, medical necessity determinations, and benefit determinations.
• Collaborate with Medical Directors on denial requests and ensure adherence to business processes.
• Coach letter writers to ensure appropriate medical necessity language in denial letters.
• Communicate frequently with physicians, practices, facilities, and allied health providers.
• Interface between Precertification staff and providers regarding policy interpretation and quality assurance issues.
• Facilitate communication between Precertification and other internal departments.
• Provide input to the Medical Policy Department on Medical Necessity Guidelines.
• Proactively identify trends in Utilization Management.
• Assist in screening appeal cases for clinical input.
• Model professionalism and leadership in all capacities of the position.

Connaissances

Utilization management

Case management

Clinical decision making

Formation

Associate Degree

BSN

Description du poste

About This Role

The Clinical Reviewer, Precertification RN, is a licensed Registered Nurse responsible for managing a clinically complex caseload of varied requests for services. This role is ideal for individuals who can work independently and collaboratively within a team environment while demonstrating sound clinical and health plan business knowledge.

Highlights

• Pay: $89,541 - $134,311/year
• Location: Remote, MA
• Schedule: Full-time

What You'll Do

• Provide clinical decision making and support for utilization management, medical necessity determinations, and benefit determinations.
• Collaborate with Medical Directors on denial requests and ensure adherence to business processes.
• Coach letter writers to ensure appropriate medical necessity language in denial letters.
• Communicate frequently with physicians, practices, facilities, and allied health providers.
• Interface between Precertification staff and providers regarding policy interpretation and quality assurance issues.
• Facilitate communication between Precertification and other internal departments.
• Provide input to the Medical Policy Department on Medical Necessity Guidelines.
• Proactively identify trends in Utilization Management.
• Assist in screening appeal cases for clinical input.
• Model professionalism and leadership in all capacities of the position.

Requirements

Education

• Associate Degree required, BSN preferred

Experience

• Five years' clinical experience in utilization management, case management, or quality assurance required
• Previous experience in a managed care setting preferred

Licenses & Certifications

• Current and unrestricted Massachusetts RN License required

Benefits

• 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

About Point32Health

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, they build on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone.