Outpatient Clinician RN Reviewer

🔥 11 minutes ago

🍂 Massachusetts – Remote

🍂 Massachusetts – Remote

💵 $89.5k - $134.3k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Point32Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Point32Health is a leading nonprofit health and well-being organization that provides health coverage and services for individuals at all life stages. Through its family of companies, including Harvard Pilgrim Health Care and Tufts Health Plan, Point32Health offers a variety of health plans, programs, and services encompassing medical, pharmacy, wellness, and behavioral health. Point32Health is committed to health equity and has been recognized for its inclusive practices, earning distinctions in areas such as health equity, disability inclusion, and LGBTQ+ workplace inclusion. With a focus on innovative solutions and high-quality coverage, Point32Health strives to create a better healthcare experience for its members and communities.

📋 Description

• Perform clinical decision-making and utilization management for clinically complex services and coverage requests • Determine medical necessity and benefit coverage using applicable coverage documents, clinical guidelines and Medical Necessity Guidelines • Ensure consistent and timely coverage decisions within product-specific compliance and regulatory timeframes • Collaborate with Medical Directors on adverse determinations and document process variances • Coach letter writers on appropriate medical necessity language for denial letters • Communicate with physicians, practices, facilities, allied health providers and external customers regarding determinations and case status • Orient new staff as needed • Liaise between Precertification staff and providers on policy interpretation, access availability and quality assurance issues • Facilitate communication between Precertification and internal departments on new program development and implementation • Provide input to the Medical Policy Department on Medical Necessity Guidelines and purchased criteria through IMPAC medical systems • Identify Utilization Management trends in precertification and outpatient UM processes • Assist with clinical screening of appeal cases • Model professionalism and leadership • Perform other assigned projects and duties

🎯 Requirements

• Current and unrestricted Massachusetts Registered Nurse license required • Associate Degree required • BSN (Bachelor of Science in Nursing) preferred • Five years’ clinical experience in utilization management, case management or quality assurance required • Previous experience in a managed care setting • Highly developed critical thinking skills • Ability to investigate, evaluate and problem solve using sound clinical judgment and business knowledge • Ability to work in an extremely complex and fast-paced production environment • Skill in responding to inquiries from providers and/or members • Initiative and creativity in planning work and resolving cases correctly, effectively, expeditiously and within tight timeframes • Good organizational skills and a customer centered focus • Ability to use multiple software applications simultaneously • Excellent oral and written communication skills • Ability to adjust work schedule on short notice • Ability to work under normal office conditions and work from home as required • Ability to use a telephone/headset and PC/keyboard simultaneously and sit for extended durations • May be required to work additional hours beyond standard work schedule

🏖️ Benefits

• 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 • Variable pay eligibility