Remote RN: Clinical Utilization & Precertification Lead

Point32Health, Inc.; Massachusetts; Remote; 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 a Clinical Reviewer, Precertification RN to manage a clinically complex caseload and support utilization management and medical necessity determinations. The role emphasizes independent and collaborative work within a team while applying sound clinical knowledge.

The position offers remote work with MA licensure and a strong benefits package, targeting experienced RNs in utilization management and related fields.

Qualifications

• Five years' clinical experience in utilization management, case management, or quality assurance.
• Massachusetts RN license required (unrestricted).]
• job_responsibilities_description:[
• Provide clinical decision making and support for utilization management, medical necessity determinations, and benefit determinations.
• Collaborate with Medical Directors on denial requests and ensure adherence to business processes.
• Coach letter writers to ensure appropriate medical necessity language in denial letters.
• Communicate frequently with physicians, practices, facilities, and allied health providers.
• Interface between Precertification staff and providers regarding policy interpretation and quality assurance issues.
• Facilitate communication between Precertification and other internal departments.
• Provide input to the Medical Policy Department on Medical Necessity Guidelines.
• Proactively identify trends in Utilization Management.
• Assist in screening appeal cases for clinical input.
• Model professionalism and leadership in all capacities of the position.

Responsibilities

• Provide clinical decision making and support for utilization management, medical necessity determinations, and benefit determinations.
• Collaborate with Medical Directors on denial requests and ensure adherence to business processes.
• Coach letter writers to ensure appropriate medical necessity language in denial letters.
• Communicate frequently with physicians, practices, facilities, and allied health providers.
• Interface between Precertification staff and providers regarding policy interpretation and quality assurance issues.
• Facilitate communication between Precertification and other internal departments.
• Provide input to the Medical Policy Department on Medical Necessity Guidelines.
• Proactively identify trends in Utilization Management.
• Assist in screening appeal cases for clinical input.
• Model professionalism and leadership in all capacities of the position.

Skills

Utilization management

Case management

Clinical decision making

Education

Associate Degree

BSN

Job description

Point32Health is seeking a Clinical Reviewer, Precertification RN to manage a clinically complex caseload and support utilization management and medical necessity determinations. The role emphasizes independent and collaborative work within a team while applying sound clinical knowledge.

The position offers remote work with MA licensure and a strong benefits package, targeting experienced RNs in utilization management and related fields.