Remote Outpatient RN Reviewer Utilization

IntelliResume; Massachusetts; On-site; USD 90,000 - 134,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Retirement plans

Paid time off

Life and disability insurance

Tuition program

Well-being benefits

Job summary

Point32Health is hiring an Outpatient Clinician RN Reviewer to manage a clinically complex caseload and determine medical necessity for members. This role emphasizes independent work within a collaborative team and involves interfacing with clinicians and Precertification staff to ensure policy interpretation and quality assurance.

The ideal candidate holds an MA RN license, an Associate Degree (BSN preferred), and at least five years in utilization management or related fields.

Qualifications

• Associate Degree required; BSN preferred.
• Five years’ clinical experience in utilization management, case management, or quality assurance.
• Current and unrestricted Massachusetts RN License required.

Responsibilities

• Provide clinical decision making for utilization management and medical necessity determinations.
• Collaborate with Medical Directors on denial requests and ensure compliance with processes.
• Coach letter writers to define medical necessity language in denial letters.
• Communicate with physicians, practices, facilities, and allied health providers.
• Interface between Precertification staff and providers regarding policy interpretation and QA.
• Facilitate communication between Precertification and other internal departments.
• Input to Medical Policy on Medical Necessity Guidelines.
• Identify trends in Utilization Management for precertification and outpatient UM processes.
• Assist in screening appeal cases with clinical input as needed.
• Model professionalism and leadership in all capacities.

Skills

Utilization management

Case management

Quality assurance

Team collaboration

Clinical decision making

Communication with providers

Education

Associate Degree

BSN preferred

Job description

Point32Health is hiring an Outpatient Clinician RN Reviewer to manage a clinically complex caseload and determine medical necessity for members. This role emphasizes independent work within a collaborative team and involves interfacing with clinicians and Precertification staff to ensure policy interpretation and quality assurance.

The ideal candidate holds an MA RN license, an Associate Degree (BSN preferred), and at least five years in utilization management or related fields.