Outpatient Clinician, RN Reviewer

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

📋 Description

• Conduct utilization management, determine medical necessity, and assess benefits for complex clinical services and coverage requests.

• Consistently apply coverage documents, clinical guidelines purchased, and Medical Necessity Guidelines within specific product timelines.

• Collaborate with Medical Directors on denial decisions, ensuring adherence to standard business processes and proper documentation.

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

• Engage with physicians, practices, facilities, allied health providers, and external customers concerning determinations and case statuses.

• Onboard new staff as required.

• Act as a liaison between Precertification personnel and providers regarding policy interpretation, access issues, and quality assurance matters.

• Facilitate communication between Precertification and internal departments as a liaison or committee member for new initiatives.

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

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

• Assist in evaluating appeal cases and offer clinical input.

• Exhibit professionalism and leadership.

• Undertake other projects and responsibilities as assigned.

⛳️ Requirements

• Must be a Registered Nurse with a current and unrestricted license in Massachusetts.

• An Associate Degree is required.

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

• Prior experience in a managed care environment is essential.

• Highly developed critical thinking abilities are required.

• Capable of investigating, evaluating, and solving problems with sound clinical judgment and business acumen.

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

• Proficient in addressing inquiries from providers and/or members.

• Demonstrated initiative and creativity in work planning.

• Ability to resolve cases accurately, effectively, and promptly within tight deadlines.

• Strong organizational skills with a customer-centered approach.

• Proficient in using multiple software applications concurrently.

• Excellent verbal and written communication skills.

• Flexibility to adjust work schedules on short notice.

• Must be able to work in a standard office environment and remotely as needed.

• Potential to work additional hours beyond the standard work schedule may be required.

🏝️ Benefits

• Coverage for medical, dental, and vision.

• Retirement plans available.

• Generous paid time off.

• Employer-funded life and disability insurance with options for additional buy-up coverage.

• Tuition assistance program.

• Well-being benefits provided.

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

• Eligibility for variable pay.