Massachusetts Licensed Clinical Reviewer

Job Summary

To support MassHealth LTSS, the remote Massachusetts Licensed Clinical Reviewer will perform pre-service clinical coverage reviews, attend appeal hearings, and collaborate with team members to ensure compliance with regulatory standards.

Key Responsibilities

• Assess the appropriateness of services for prior authorizations based on documentation and guidelines
• Attend appeal hearings and represent prior authorization determinations while collaborating with internal stakeholders
• Maintain compliance with MassHealth clinical guidelines and ensure accurate documentation of decisions

Required Qualifications

• Current Massachusetts clinical licensure as required for the role
• Experience in clinical coverage review and familiarity with MassHealth policies
• Ability to work independently and collaboratively within a team environment
• Strong understanding of regulatory requirements related to clinical operations
• Proficiency in clinical systems and documentation tools