Massachusetts RN Clinical Care Reviewer

Job Summary

Working remotely on a full-time basis, the Massachusetts RN Clinical Care Reviewer will process medical necessity reviews for healthcare services, assist with discharge planning, and coordinate care for members while ensuring compliance with regulations.

Key responsibilities:

• Complete prospective, concurrent, and retrospective reviews for various healthcare services including inpatient admissions and homecare
• Engage with care partners to facilitate transitions to appropriate levels of care and communicate quality issues to Quality Improvement
• Provide guidance to clinical and non-clinical staff and attend medical advisement meetings as needed

Required qualifications:

• Current, unrestricted Registered Nurse (RN) Licensure in Massachusetts
• Completion of an accredited registered nursing degree program (A.S. required)
• Three years of clinical experience, with preference for med/surgical, emergency acute care, or home health experience
• Experience in Utilization Management/Utilization Review preferred
• MCG Certification or ability to obtain within six months of hire