Remote Precertification RN — Utilization Review

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

Benefits offered by this job

Medical, dental and vision coverage

Retirement plans

Paid time off

Tuition program

Well-being benefits

Job summary

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

You will work in a team dedicated to precertification and outpatient utilization management, collaborating with Medical Directors and providers. A Massachusetts license is required with an RN background and at least five years in utilization management or related fields.

Qualifications

• Requires highly developed critical thinking skills and the ability to investigate, evaluate and problem solve using sound clinical judgment and business knowledge.
• Ability to work in an extremely complex and fast-paced production environment.
• Excellent oral and written communication skills required.

Responsibilities

• Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations.
• Collaborates with Medical Directors when determination to deny a request is indicated and ensures processes are followed.
• Coaches letter writers to assure appropriate medical necessity language in denial letters.
• Communicates with physicians, practices, facilities, and allied health providers.
• Interfaces between Precertification staff and providers to ensure timely coverage decisions within guidelines.
• Acts as a liaison on new programs and contributes input to Medical Policy and IMPAC systems.

Skills

Critical thinking

Fast-paced environment

Communication skills

Education

Associate Degree

BSN preferred

Job description

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

You will work in a team dedicated to precertification and outpatient utilization management, collaborating with Medical Directors and providers. A Massachusetts license is required with an RN background and at least five years in utilization management or related fields.