Remote Precertification RN Reviewer – Outpatient

P32HS Point32Health Services Inc; Massachusetts; Hybrid; USD 90,000 - 134,000; Full time

Benefits offered by this job

Medical coverage

Retirement plans

Paid time off

Life insurance

Tuition program

Well-being benefits

Job summary

Point32Health is seeking a Clinical Reviewer, Precertification RN, in Massachusetts. You will manage a clinically complex caseload, determine medical necessity and coverage for members, and ensure timely, compliant decisions within product-specific time frames.

The role requires an active MA RN license, an associate degree (BSN preferred), and at least five years in utilization management or related fields.

Qualifications

• Registered Nurse with current MA license (unrestricted).
• Associate Degree required; BSN preferred.
• Five years of clinical experience in utilization management, case management, or quality assurance in managed care.

Responsibilities

• Perform utilization management, determine medical necessity and benefit coverage for members.
• Collaborate with Medical Directors when denial is indicated and document processes.
• Coach letter writers to ensure precise medical necessity language in denial letters.
• Communicate regularly with physicians, practices, facilities, and allied health providers.
• Interface with Precertification staff and providers to ensure timely coverage decisions within regulatory guidelines.

Skills

Critical thinking

Communication

Education

Associate Degree

BSN (preferred)

Job description

Point32Health is seeking a Clinical Reviewer, Precertification RN, in Massachusetts. You will manage a clinically complex caseload, determine medical necessity and coverage for members, and ensure timely, compliant decisions within product-specific time frames.

The role requires an active MA RN license, an associate degree (BSN preferred), and at least five years in utilization management or related fields.