Remote Precertification RN — Outpatient UM

Point32Health, Inc.; United States; Hybrid; USD 90,000 - 134,000; Full time

Job summary

Point32Health, Inc. is seeking a Clinical Reviewer, Precertification RN to manage a clinically complex caseload and determine medical necessity and benefit coverage for members.

The role sits on the Precertification / Outpatient Utilization Management team and reports to the Team Manager or department Director. The ideal candidate will demonstrate sound clinical judgment, the ability to work independently and within a team, and comfort navigating product-specific compliance and regulatory

Qualifications

• RN with current Massachusetts license.
• Five years’ clinical experience in utilization management, case management or quality assurance in a managed care setting.
• Strong communication, organizational and analytical skills.

Responsibilities

• Provide clinical decision making for utilization management, medical necessity determinations and benefit determinations.
• Collaborate with Medical Directors on denials and ensure processes are followed; escalate variances as needed.
• Coach letter writers to ensure appropriate medical necessity language in denial letters.
• Communicate with physicians, practices, facilities, and allied health providers daily.
• Act as liaison between Precertification and other departments for policy interpretation and program implementation.
• Provide input to Medical Policy on Medical Necessity Guidelines and IMPAC system inputs.
• Identify trends in Utilization Management relevant to precertification and outpatient UM processes.
• Assist in screening appeal cases to provide clinical input as needed.
• Model professionalism and leadership; perform other duties as assigned.

Skills

Critical thinking

Communication

Multitasking

Problem solving

Time management

Education

Associate Degree

BSN

Job description

Point32Health, Inc. is seeking a Clinical Reviewer, Precertification RN to manage a clinically complex caseload and determine medical necessity and benefit coverage for members.

The role sits on the Precertification / Outpatient Utilization Management team and reports to the Team Manager or department Director. The ideal candidate will demonstrate sound clinical judgment, the ability to work independently and within a team, and comfort navigating product-specific compliance and regulatory