Job Summary
The Clinical Reviewer, Precertification RN, is a licensed Registered Nurse that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for determining medical necessity and benefit coverage for Point32Health members. The Clinical Reviewer ensures consistent and timely disposition of coverage decisions as required by product specific compliance and regulatory time frames. The Clinical Reviewer functions as a member of the Precertification / Outpatient Utilization Management (UM) team and works under the general direction of the Precertification Team Manager or department Director. The Clinical Reviewer is expected to demonstrate the ability to work independently as well as collaboratively within a team environment. The Clinical Reviewer will be expected to demonstrate sound clinical and health plan business knowledge in their decision-making processes, on behalf of the health plan.
Key Responsibilities/Duties – what you will be doing
- Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames.
- Collaborates with Medical Directors when determination to deny a request is indicated, advising the Medical Directors on standard business processes, ensuring those processes are followed or variances to the process are escalated, if needed, and agreed to and well documented.
- Coaches letter writers to assure that appropriate medical necessity language is clearly defined in the denial letter.
- Communicates frequently through the day with physicians, practices, facilities, and/or allied health providers.
- Communicates frequently through the day with external customers (agents acting on behalf of the provider or member or both) regarding the rational for a determination, as well as the status and disposition of cases.
- Orients new staff to role as needed.
- Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.
- Facilitates communication between Precertification and other internal departments by acting as a liaison or committee member on the development or implementation of new programs.
- Provides input to the Medical Policy Department regarding the development of Medical Necessity Guidelines and adding input to purchased criteria through participation in the IMPAC medical systems.
- Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM processes.
- Assists in the screening of appeal cases to provide clinical input as needed or requested.
- Models professionalism and leadership in all capacities of the position to all audiences.
- Other projects and duties as assigned.
Qualifications – what you need to perform the job
Certification and Licensure
- Registered Nurse with a current and unrestricted Massachusetts license required
Education
- Required (minimum): Associate Degree
- Preferred: BSN (Bachelor of Science in Nursing)
Experience
- Required (minimum): Five years’ clinical experience in utilization management, case management or quality assurance. Previous experience in a managed care setting.
- Preferred:
Skill Requirements
- Requires an individual with highly developed critical thinking skills and the ability to investigate, evaluate and problem solve using sound clinical judgment and business knowledge.
- Requires the ability to work in an extremely complex and fast-paced production environment.
- Demonstrates skill in responding to inquiries from providers and/or members
- Must exhibit initiative and creativity in planning of work and be able to resolve cases correctly, effectively, expeditiously and within tight timeframes.
- Good organizational skills and a customer centered focus required.
- Individual must be able to use multiple software applications simultaneously.
- Excellent oral and written communication skills required.
Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):
- Fast paced business environment that requires prioritization and balancing of multiple demands.
- Continuous use of PC and telephone required.
- Ability to adjust work schedule on short notice to adapt to departmental, case driven needs.
- Must be able to work under normal office conditions and work from home as required.
- Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
- May be required to work additional hours beyond standard work schedule.
Salary Range
$89,540.84 -$134,311.26