Clinical Reviewer, Precertification RN

The Clinical Reviewer, Precertification RN, is a licensed Registered Nurse responsible for managing a clinically complex caseload of varied requests for services. This role is ideal for individuals who can work independently and collaboratively within a team environment while demonstrating sound clinical and health plan business knowledge.

• Pay: $89,541 - $134,311/year
• Location:
  
  Remote, MA
• Schedule:
  
  Full-time

• Provide clinical decision making and support for utilization management, medical necessity determinations, and benefit determinations.
• Collaborate with Medical Directors on denial requests and ensure adherence to business processes.
• Coach letter writers to ensure appropriate medical necessity language in denial letters.
• Communicate frequently with physicians, practices, facilities, and allied health providers.
• Interface between Precertification staff and providers regarding policy interpretation and quality assurance issues.
• Facilitate communication between Precertification and other internal departments.
• Provide input to the Medical Policy Department on Medical Necessity Guidelines.
• Proactively identify trends in Utilization Management.
• Assist in screening appeal cases for clinical input.
• Model professionalism and leadership in all capacities of the position.

• Associate Degree required, BSN preferred

• Five years' clinical experience in utilization management, case management, or quality assurance required
• Previous experience in a managed care setting preferred

• Current and unrestricted Massachusetts RN License required

• Medical, dental, and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

Point
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Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, they build on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone.