Senior Clinical Review Specialist

New England Life Care, Inc.; Canton (MA); On-site; USD 33,000 - 34,000; Full time

Benefits offered by this job

Health insurance

Vision insurance

403(b) savings program

Job summary

New England Life Care, Inc. is seeking a Senior Clinical Review Specialist in Canton, MA for a full‑time remote/onsite hybrid role with a strong emphasis on clinical criteria and payer policies.

The ideal candidate has medical experience, understands utilization review, and can communicate decisions effectively to providers and members while ensuring compliance with state and federal regulations.

Qualifications

• Healthcare experience in a medical setting is required.
• Experience in utilization review and quality review is preferred.
• Familiarity with federal/state regulations and payer contracts is needed.

Responsibilities

• Apply clinical skills with medical criteria to ensure high‑quality, cost‑effective care.
• Maintain understanding of regulations, payer contracts, product lines and NELC procedures.
• Serve as subject matter expert on complex specialty drugs and clinical requirements.
• Review clinical documentation for government payers to confirm coverage and notify Medical Director of denials that don’t meet medical necessity.
• Coordinate with internal and external customers to obtain signed physician orders for government payers.
• Determine appropriateness and effectiveness of services using established criteria and policies.
• Document medical reviews with rationale in a timely, compliant manner and address urgent cases per state rules.
• Communicate coverage decisions clearly to members, providers and medical groups within regulatory timelines.

Skills

Healthcare experience

Utilization review

Regulatory knowledge

Communication skills

Deductive reasoning

Education

Medical Assistant certification

Associate degree or higher

MA or LPN preferred

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Senior Clinical Review Specialist

Full Time Professional Canton, MA, US

Salary Range: $24.00 To $25.00 Hourly

New England Life Care (NELC) is one of the fastest growing home infusion therapy companies in New England and is the region’s only non-profit home infusion provider. NELC is a hospital collaborative serving more than 70 hospital systems in Maine, New Hampshire, and Massachusetts. NELC was created by local hospitals to ensure their patients have access to a provider that reflects their commitment to excellence in patient care, quality, and service. Like our owner hospitals, NELC provides patient focused care.

New England Life Care has and continues to build a diverse, inclusive, and authentic workplace, so if you’re energized by this opportunity, but your experience doesn’t support every qualification in the job posting, we encourage you to apply! You still may be the person we are looking for!

Remote Clinical Review Specialist opportunity available. This is a remote position with an ideal Monday – Friday from 8:30am until 5:00pm schedule. The ideal candidate for this position will excel in a fast-paced environment, have excellent communication and deductive reasoning skills.

**We are only hiring remote employees for this position that live in Maine, Massachusetts, and New Hampshire.**

Summary

The Clinical Review Specialist will conduct regular utilization management reviews and provide clinical information as required in order to confirm coverage for each patient.

• Health insurance
• Vision insurance
• Generous employer-matched 403(b) savings program
• Company paid: Life insurance, Short- and long-term disability insurance
• Paid Time Off
• And much more!

Primary Responsibilities

• Apply clinical skills and expertise in conjunction with established medical criteria, members’ eligibility and benefit coverage information, in the review of therapy checklists & specialist drug authorization forms, to ensure high-quality, cost-effective care
• Maintain a thorough and comprehensive understanding of regulations, payer contracts, product lines, NELC policies & procedures.
• Serves as subject matter expert on complex specialty drugs clinical requirements.
• Review clinical documentation for long term government payers to ensure they still meet clinical coverage twice a year. Consulting with the Medical Director for all potential denials that do not meet medical necessity or NELC criteria. The decision for a medically necessary denial is within the Medical Director role
• Act as a liaison between internal and external customers to resolve systems/process issues and ensure we are obtaining signed physician orders from participating MDs for government payers.
• Determine appropriateness and effectiveness of services requested using established medical coverage criteria, guidelines and departmental policies and procedures
• Responsible for timely and comprehensive medical review with concise documentation of pertinent facts, decisions and rationale and facilitation of resolution to requests of “urgently needed, not yet rendered services” in compliance with state regulation.
• Effectively and accurately communicate coverage decisions to members, providers, and medical groups, following timelines established by regulations and accreditation standards.
• Identify and appropriately inform Manager/Supervisor of sensitive or complex cases
• Maintains a thorough and comprehensive understanding of state and federal regulations, accreditation standards and payer contracts to ensure compliance.
• Develop and maintain positive, effective working relationships with Medical Directors, physicians, vendors, managed care offices and other customers
• Maintain confidentiality of member and case information by following Corporate Privacy policies pertaining to protection of member PHI
• Perform other duties as assigned

Mandatory and Preferred Requirements

• Medical Assistant certification required
• MA or LPN preferred
• Associate of Arts degree or higher are preferred
• Healthcare experience in a medical setting required
• Prior experience in care coordination, home health or home infusion preferred
• Experience in managed care environment
• Experience in working with established criteria to determine medical necessity and appropriateness of care
• Experience in utilization review, utilization management, quality review
• Working knowledge of federal / state fraud and abuse laws required
• Knowledge of HIPAA Privacy and Security Regulations preferred.

Skills

• Dependability in attendance and job performance required
• Excellent verbal and written communication and interpersonal skills
• Excellent problem identification and solving skills
• Ability to organize and prioritize multiple assignments within workload
• Ability to function independently and take independent action, within scope of job responsibilities
• Competency in computer skills including Microsoft work, outlook and internet

“It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.”

EOE