Remote Clinical Review Specialist - payer & coverage expert

New England Life Care, Inc.; Milton (MA); Remote; USD 60,000 - 85,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

Generous 403(b) employer‑matched plan

Life insurance included

Short- and long‑term disability

Paid Time Off

Career Ladder

Job summary

New England Life Care, Inc. is seeking a Remote Clinical Review Specialist to perform utilization management reviews and provide essential clinical information to confirm patient coverage. The role emphasizes regulatory compliance, complex specialty drug knowledge, and liaison work with providers.

The position requires Medical Assistant certification and healthcare experience, with LPN as a preferred credential. Remote work is available for residents of Maine, Massachusetts, and New Hampshire.

Qualifications

• Healthcare experience in a medical setting is required.
• Experience with utilization review and payer criteria to determine medical necessity.
• Knowledge of federal/state fraud and abuse laws is required.
• Familiarity with HIPAA Privacy and Security Regulations is preferred.

Responsibilities

• Conduct utilization management reviews and provide clinical information to confirm coverage.
• Review therapy checklists and specialist drug authorization forms for cost‑effective care.
• Maintain understanding of regulations, payer contracts and NELC policies.
• Act as subject matter expert on complex specialty drugs and clinical requirements.
• Communicate coverage decisions clearly to members, providers and groups.

Skills

Healthcare experience

Utilization review

Medical necessity

Regulatory compliance

HIPAA awareness

Communication skills

Education

Medical Assistant certification

Associate of Arts degree or higher

Licensed Practical Nurse (LPN) preferred

Job description

New England Life Care, Inc. is seeking a Remote Clinical Review Specialist to perform utilization management reviews and provide essential clinical information to confirm patient coverage. The role emphasizes regulatory compliance, complex specialty drug knowledge, and liaison work with providers.

The position requires Medical Assistant certification and healthcare experience, with LPN as a preferred credential. Remote work is available for residents of Maine, Massachusetts, and New Hampshire.