RN Precertification Clinician: Utilization Review Pro

Point32Health, Inc.; United States; On-site; USD 90,000 - 134,000; Full time

Benefits offered by this job

Medical insurance

Retirement plans

Paid time off

Tuition program

Well-being benefits

Life and disability insurance

Job summary

Point32Health is seeking a Clinical Reviewer, Precertification RN, a licensed nurse who will independently manage a clinically complex caseload to determine medical necessity and coverage for members. The role sits within Precertification/Outpatient Utilization Management and requires strong clinical and health plan knowledge.

The candidate will collaborate with Medical Directors, coach letter writers, and coordinate with multiple internal and external stakeholders to ensure timely disposition

Qualifications

• Registered Nurse with a current and unrestricted MA license required.
• Minimum of five years’ clinical experience in utilization management, case management or quality assurance; managed care experience preferred.
• Associate degree required; BSN preferred.

Responsibilities

• Perform utilization management, medical necessity determinations and benefit determinations per coverage documents and guidelines within specified timeframes.
• Collaborate with Medical Directors on denials and advise on standard processes; escalate variances as needed.
• Coach letter writers to ensure clear medical necessity language in denial letters.
• Communicate regularly with physicians, practices, facilities, and external customers regarding determinations and case status.
• Assist in staff orientation and act as liaison between Precertification and other departments to ensure timely coverage decisions.

Skills

Critical thinking

Communication

Organizational skills

Multitasking

Customer focus

Interpersonal communication

Education

Associate Degree

BSN preferred

Job description

Point32Health is seeking a Clinical Reviewer, Precertification RN, a licensed nurse who will independently manage a clinically complex caseload to determine medical necessity and coverage for members. The role sits within Precertification/Outpatient Utilization Management and requires strong clinical and health plan knowledge.

The candidate will collaborate with Medical Directors, coach letter writers, and coordinate with multiple internal and external stakeholders to ensure timely disposition