Senior Remote 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

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.