Outpatient clinician RN reviewer

Who We Are

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, Point
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Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are.

We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point
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Health.

The Clinical Reviewer, Precertification RN, is a licensed Registered Nurse that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for determining medical necessity and benefit coverage for Point
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Health members.

The Clinical Reviewer ensures consistent and timely disposition of coverage decisions as required by product specific compliance and regulatory time frames. The Clinical Reviewer functions as a member of the Precertification / Outpatient Utilization Management (UM) team and works under the general direction of the Precertification Team Manager or department Director. The Clinical Reviewer is expected to demonstrate the ability to work independently as well as collaboratively within a team environment.

The Clinical Reviewer will be expected to demonstrate sound clinical and health plan business knowledge in their decision-making processes, on behalf of the health plan.

• Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames.
• Collaborates with Medical Directors when determination to deny a request is indicated, advising the Medical Directors on standard business processes, ensuring those processes are followed or variances to the process are escalated, if needed, and agreed to and well documented.
• Coaches letter writers to assure that appropriate medical necessity language is clearly defined in the denial letter.
• Communicates frequently through the day with physicians, practices, facilities, and/or allied health providers.
• Communicates frequently through the day with external customers (agents acting on behalf of the provider or member or both) regarding the rational for a determination, as well as the status and disposition of cases.
• Orients new staff to role as needed.
• Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.
• Facilitates communication between Precertification and other internal departments by acting as a liaison or committee member on the development or implementation of new programs.
• Provides input to the Medical Policy Department…