RN Precertification Clinician — Outpatient UM

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

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Retirement plans

Paid time off

Life insurance

Disability insurance

Tuition program

Well-being benefits

Job summary

Point32Health is seeking a Clinical Reviewer, Precertification RN, to manage a clinically complex caseload and determine medical necessity and coverage for members. This role works within the Precertification/Outpatient Utilization Management team and reports to the Team Manager, operating independently while collaborating with physicians and internal departments.

The successful candidate will hold MA RN licensure, have 5+ years in utilization management, case management or quality assurance,

Qualifications

• Registered Nurse with a current and unrestricted Massachusetts license
• Five years’ clinical experience in utilization management, case management or quality assurance

Responsibilities

• Provide clinical decision making for utilization management and medical necessity determinations.
• Collaborate with Medical Directors when denials are indicated and document processes accordingly.
• Coach letter writers to ensure appropriate medical necessity language in denial letters.
• Communicate with physicians, practices, facilities and external customers regarding determinations and status of cases.
• Interface between Precertification staff and providers to ensure timely coverage decisions within regulatory guidelines.
• Identify trends in Utilization Management relevant to precertification and outpatient UM processes.

Skills

Critical thinking

Clinical judgment

Communication skills

Time management

Education

Associate Degree

BSN

Job description

Point32Health is seeking a Clinical Reviewer, Precertification RN, to manage a clinically complex caseload and determine medical necessity and coverage for members. This role works within the Precertification/Outpatient Utilization Management team and reports to the Team Manager, operating independently while collaborating with physicians and internal departments.

The successful candidate will hold MA RN licensure, have 5+ years in utilization management, case management or quality assurance,