Remote Clinical Review Specialist (Utilization & Compliance)

New England Life Care, Inc.; Maine; Remote; USD 65,000 - 85,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

Generous 403(b) savings program

Company paid life insurance and short/

long-term disability insurance

Paid Time Off

Job summary

New England Life Care, Inc. is seeking a Remote Clinical Review Specialist in a Monday–Friday schedule from 8:30am to 5:00pm. The role requires strong clinical review skills and excellent communication to confirm coverage for patients within a fast-paced home infusion setting.

Must reside in Maine, Massachusetts, or New Hampshire. The position emphasizes utilization management reviews, adherence to payer contracts, and collaboration with Medical Directors to ensure compliant, high-quality

Qualifications

• Dependable and reliable attendance and performance.
• Excellent verbal and written communication skills.
• Strong problem-solving abilities and analytical thinking.
• Able to manage multiple tasks and prioritize effectively.
• Capable of working independently within role responsibilities.
• Proficient with computer software including Microsoft Office.

Responsibilities

• Apply clinical criteria with patient eligibility and coverage information to ensure quality, cost-effective care.
• Maintain up-to-date knowledge of regulations, payer contracts, and NELC policies and procedures.
• Serve as subject matter expert on complex specialty drugs and clinical requirements.
• Review documentation for long-term government payers to verify ongoing medical necessity; consult Medical Director for potential denials.
• Coordinate with internal and external stakeholders to obtain signed physician orders for government payers.
• Assess appropriateness and effectiveness of services using established coverage criteria and department policies.
• Document medical reviews clearly with rationale and respond to urgent service requests per state regulations.
• Communicate coverage decisions to members, providers, and medical groups within regulatory timelines.
• Flag sensitive or complex cases to Manager/Supervisor as needed.
• Maintain understanding of state/federal regulations and payer contracts for compliance.
• Cultivate positive relationships with Medical Directors, physicians, vendors, and managed care teams.
• Protect member PHI by following privacy policies.
• Perform other duties as assigned.

Skills

Dependability

Verbal and written communication

Problem solving

Organization & prioritization

Independence

Computer skills (MS Office)

Education

Medical Assistant certification

MA or LPN preferred

Associate degree or higher

Job description

New England Life Care, Inc. is seeking a Remote Clinical Review Specialist in a Monday–Friday schedule from 8:30am to 5:00pm. The role requires strong clinical review skills and excellent communication to confirm coverage for patients within a fast-paced home infusion setting.

Must reside in Maine, Massachusetts, or New Hampshire. The position emphasizes utilization management reviews, adherence to payer contracts, and collaboration with Medical Directors to ensure compliant, high-quality