Outpatient Clinician RN Reviewer

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

📋 Description

• Conduct clinical decision-making and utilization management for services and coverage requests that are clinically intricate.

• Assess medical necessity and benefit coverage by referencing relevant coverage documents, clinical guidelines, and Medical Necessity Guidelines.

• Ensure timely and consistent coverage decisions comply with product-specific regulations and deadlines.

• Work in collaboration with Medical Directors regarding adverse determinations and document any process deviations.

• 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 progress.

• Provide orientation for new staff members as necessary.

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

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

• Offer insights to the Medical Policy Department regarding Medical Necessity Guidelines and purchased criteria through IMPAC medical systems.

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

• Aid in the clinical assessment of appeal cases.

• Exemplify professionalism and leadership qualities.

• Execute other assigned projects and responsibilities.

⛳️ Requirements

• A current and unrestricted Massachusetts Registered Nurse license is mandatory.

• An Associate Degree is required.

• A BSN (Bachelor of Science in Nursing) is preferred.

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

• Prior experience in a managed care environment is needed.

• Strong critical thinking skills are essential.

• Ability to investigate, assess, and resolve problems using sound clinical judgment and business acumen.

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

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

• Initiative and creativity in planning work and effectively resolving cases promptly and accurately within tight deadlines.

• Strong organizational skills coupled with a customer-centered focus.

• Competence in using multiple software applications concurrently.

• Exceptional oral and written communication skills are essential.

• Flexibility to adjust work schedule on short notice is required.

• Ability to work in a standard office environment and remotely as needed.

• Capability to use a telephone/headset and PC/keyboard simultaneously and to sit for extended periods.

• May need to work additional hours beyond the standard work schedule.

🏝️ Benefits

• Comprehensive medical, dental, and vision coverage.

• Retirement savings plans.

• Paid time off benefits.

• Employer-sponsored life and disability insurance with options for additional coverage.

• Tuition assistance program.

• Well-being benefits.

• A full range of benefits aimed at supporting career development, individual and family health, and financial well-being.

• Eligibility for variable pay.