Remote RN - Precetification & Utilization Review

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

Benefits offered by this job

Medical, dental and vision coverage

Retirement plans

Paid time off

Well-being benefits

Job summary

Point32Health in Massachusetts is seeking a Clinical Reviewer, Precertification RN, to independently manage a clinically complex caseload and determine medical necessity and benefit coverage for members. The role ensures consistent, timely disposition of coverage decisions within regulatory time frames.

The position requires MA licensure, an Associate Degree, five years in utilization management or managed care, and collaboration with Medical Directors.

Qualifications

• RN license in MA is required.
• Associate degree required; BSN preferred.
• Five years of clinical experience in utilization management or managed care.

Responsibilities

• Provides clinical decision making for utilization management and medical necessity determinations.
• Collaborates with Medical Directors when denial determinations are indicated.
• Coaches letter writers to ensure accurate medical necessity language.
• Communicates with physicians, practices, facilities, and allied health providers.
• Interfaces with internal departments to ensure timely coverage decisions.
• Identifies trends in Utilization Management and supports new programs.

Skills

Critical thinking

Communication skills

Independent worker

Education

Associate Degree

BSN preferred

Job description

Point32Health in Massachusetts is seeking a Clinical Reviewer, Precertification RN, to independently manage a clinically complex caseload and determine medical necessity and benefit coverage for members. The role ensures consistent, timely disposition of coverage decisions within regulatory time frames.

The position requires MA licensure, an Associate Degree, five years in utilization management or managed care, and collaboration with Medical Directors.