Massachusetts Licensed RN Reviewer

Job Summary

Managing a clinically complex caseload, the full-time Massachusetts Licensed RN Reviewer will determine medical necessity and benefit coverage for services, ensuring timely disposition of coverage decisions while working remotely.

Key responsibilities

• Perform utilization management and medical necessity determinations using clinical guidelines and coverage documents
• Collaborate with Medical Directors on denial requests and coach letter writers on appropriate medical necessity language
• Facilitate communication between Precertification staff and providers to ensure timely coverage decisions

Required qualifications

• Current and unrestricted Massachusetts Registered Nurse license
• Associate Degree in Nursing required; BSN preferred
• Minimum of five years' clinical experience in utilization management, case management, or quality assurance
• Experience in a managed care setting preferred
• Strong critical thinking skills and ability to work in a fast-paced environment