Remote Outpatient RN Reviewer | Utilization Management

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 seeking an Outpatient Clinician RN Reviewer to manage a clinically complex caseload, determine medical necessity and benefit coverage for members. You can work independently and with a team in a remote MA setting, with a focus on utilization management and quality assurance.

The role requires an active MA RN license, five years of relevant experience, and a willingness to collaborate with Medical Directors to ensure compliant denial decisions and accurate medical necessity

Qualifications

• Associate degree in nursing required; BSN preferred.
• Five years of clinical experience in utilization or case management.
• Massachusetts RN license active and unrestricted.

Responsibilities

• Provide clinical decision making for utilization management and medical necessity.
• Collaborate with Medical Directors on denial requests and ensure compliance.
• Coach letter writers to define appropriate medical necessity language.
• Interface with physicians and providers to discuss policy interpretation.

Skills

Utilization management

Case management

Quality assurance

Clinical decision making

Provider communication

Leadership

Education

Associate Degree

BSN preferred

Job description

Point32Health is seeking an Outpatient Clinician RN Reviewer to manage a clinically complex caseload, determine medical necessity and benefit coverage for members. You can work independently and with a team in a remote MA setting, with a focus on utilization management and quality assurance.

The role requires an active MA RN license, five years of relevant experience, and a willingness to collaborate with Medical Directors to ensure compliant denial decisions and accurate medical necessity