Outpatient Clinician, RN Reviewer

This is a fully remote position, open to applicants in Massachusetts.

📋 Description

• Oversee a clinically intricate caseload encompassing diverse service requests.

• Conduct utilization management, determine medical necessity, and make benefit determinations utilizing coverage documents, clinical guidelines, and Medical Necessity Guidelines.

• Guarantee timely and consistent coverage decisions in alignment with product-specific compliance and regulatory deadlines.

• Collaborate with Medical Directors on decisions regarding denials and business processes.

• Guide letter writers on the appropriate medical necessity terminology for denial communications.

• Engage with physicians, practices, facilities, allied health providers, and external clients about determinations and case updates.

• Onboard new staff as necessary.

• Serve as a liaison between Precertification personnel and providers concerning policy interpretation, access availability, and quality assurance concerns.

• Enhance communication between Precertification and internal teams regarding the development or execution of new programs.

• Provide feedback to the Medical Policy Department on Medical Necessity Guidelines and purchased criteria through IMPAC medical systems.

• Recognize trends in Utilization Management within precertification and outpatient UM processes.

• Assist in screening appeal cases and offer clinical insights.

• Exemplify professionalism and leadership.

• Complete additional projects and responsibilities as assigned.

⛳️ Requirements

• Must possess a current and unrestricted Massachusetts Registered Nurse license.

• An Associate Degree is required.

• A minimum of five years of clinical experience in utilization management, case management, or quality assurance is necessary.

• Previous experience in a managed care environment is essential.

• Strong critical thinking skills are crucial.

• Capability to investigate, assess, and solve problems using sound clinical judgment and business acumen.

• Ability to thrive in a highly complex and fast-paced production setting.

• Proficient in responding to inquiries from providers and/or members.

• Demonstrated initiative and creativity in work planning.

• Ability to resolve cases accurately, efficiently, and within stringent time constraints.

• Strong organizational skills with a customer-centered approach.

• Proficient in using multiple software applications concurrently.

• Excellent written and verbal communication skills.

• Flexibility to adjust work schedules on short notice.

• Ability to work under standard office conditions and remotely as needed.

• Willingness to work additional hours beyond the standard schedule when required.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Retirement plan options.

• Paid time off.

• Employer-sponsored life and disability insurance with additional buy-up options.

• Tuition assistance program.

• Well-being benefits.

• Comprehensive benefits package to support career advancement, individual & family health, and financial well-being.

• Eligibility for variable pay.