Remote Outpatient Utilization RN | Medical Necessity Expert

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 and determine medical necessity for members. This remote MA role requires an RN license and five years in utilization management or related fields, with BSN preferred.

The position emphasizes independent work within a team, partnering with Medical Directors, and adherence to established processes to ensure timely coverage decisions.

Qualifications

• Associate degree is required; BSN preferred.
• Five years of clinical experience in utilization management, case management, or quality assurance.
• Massachusetts RN license (current and unrestricted).

Responsibilities

• Provide clinical decision-making and support for UM and medical necessity determinations.
• Collaborate with Medical Directors on denial requests and ensure adherence to processes.
• Coach letter writers to define appropriate 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 quality assurance.
• Facilitate communication between Precertification and other internal departments.
• Provide input to Medical Policy on Medical Necessity Guidelines.
• Identify trends in Utilization Management related to precertification and outpatient processes.
• Assist in screening appeal cases for clinical input as needed.
• Model professionalism and leadership in all capacities of the position.

Skills

Clinical decision-making

Utilization management

Collaboration

Communication with providers

Education

Associate degree

BSN preferred

Job description

Point32Health is seeking an Outpatient Clinician RN Reviewer to manage a clinically complex caseload and determine medical necessity for members. This remote MA role requires an RN license and five years in utilization management or related fields, with BSN preferred.

The position emphasizes independent work within a team, partnering with Medical Directors, and adherence to established processes to ensure timely coverage decisions.