Massachusetts RN Clinical Care Reviewer

Job Summary

To support healthcare service authorization, the full-time Massachusetts RN Clinical Care Reviewer will process medical necessity reviews, assist with discharge planning, and coordinate care for members in a remote setting.

Key responsibilities:

• Complete prospective, concurrent, and retrospective reviews for various healthcare services
• Engage with care partners and medical directors to facilitate transitions and ensure appropriate care levels
• Identify quality issues and refer members for Care Management as needed

Required qualifications:

• Current, unrestricted Registered Nurse (RN) Licensure in Massachusetts
• Associate's degree or completion of an accredited registered nursing (RN) degree program
• Three years of clinical experience, preferably in med/surgical, emergency acute care, or home health
• Utilization Management/Utilization Review experience preferred
• MCG Certification or ability to obtain within six months of hire