Precertification RN — Clinical Utilization Specialist

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

Benefits offered by this job

Medical, dental and vision coverage

Retirement plans

Paid time off

Life and disability insurance

Tuition program

Well-being benefits

Job summary

Point32Health is seeking a Clinical Reviewer, Precertification RN, licensed as an RN in Massachusetts, to manage a clinically complex caseload and determine medical necessity and benefit coverage for members.

The role is part of the Precertification / Outpatient Utilization Management team and requires independent work as well as collaboration, with strong clinical judgment and knowledge of utilization management processes to ensure timely decisions within regulatory guidelines.

Qualifications

• Registered Nurse with MA license required.
• Associate degree required; BSN preferred.
• Minimum five years of clinical experience in utilization management, case management or quality assurance.
• Managed care experience is a plus.

Responsibilities

• Provide clinical decision making for utilization management and medical necessity determinations.
• Collaborate with Medical Directors when denials are indicated and document processes.
• Coach letter writers to ensure clear medical necessity language.
• Communicate with physicians, facilities and external customers regarding determinations.
• Work independently and as part of the Precertification/UM team to meet regulatory timelines.

Skills

Critical thinking

Communication skills

Clinical nursing experience

Utilization management knowledge

Education

Associate Degree RN

BSN preferred

Tools

EHR systems

Utilization management software

Job description

Point32Health is seeking a Clinical Reviewer, Precertification RN, licensed as an RN in Massachusetts, to manage a clinically complex caseload and determine medical necessity and benefit coverage for members.

The role is part of the Precertification / Outpatient Utilization Management team and requires independent work as well as collaboration, with strong clinical judgment and knowledge of utilization management processes to ensure timely decisions within regulatory guidelines.