Massachusetts Licensed Clinical Review Specialist

Job Summary

Working remotely, the full-time Massachusetts Licensed Clinical Review Specialist will conduct utilization management reviews and provide clinical information to confirm patient coverage, ensuring high-quality and cost-effective care.

Key responsibilities:

• Apply clinical expertise to review therapy checklists and authorization forms in line with medical criteria and member eligibility
• Act as a subject matter expert on specialty drugs and maintain compliance with regulations, payer contracts, and NELC policies
• Effectively communicate coverage decisions and resolve issues with internal and external stakeholders while maintaining confidentiality

Required qualifications:

• Medical Assistant certification is required
• Healthcare experience in a medical setting is required
• Experience in care coordination or home health is preferred
• Working knowledge of federal/state fraud and abuse laws is required
• Knowledge of HIPAA Privacy and Security Regulations is preferred