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, ensuring timely decisions while working remotely.

Key responsibilities:

• Perform utilization management and medical necessity determinations for service requests within established time frames
• Collaborate with Medical Directors on denial requests and coach staff on appropriate medical necessity language in denial letters
• Facilitate communication between Precertification staff and providers, ensuring timely coverage decisions and addressing policy interpretation issues

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 is preferred
• Highly developed critical thinking skills and ability to work in a fast-paced environment