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 members while working remotely and ensuring compliance with regulatory time frames.

Key Responsibilities

• Conducts utilization management and medical necessity determinations for complex service requests within established time frames
• Collaborates with Medical Directors on denial decisions and ensures proper documentation of processes
• Facilitates communication between Precertification staff and providers, addressing policy interpretation and quality assurance issues

Required Qualifications

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