Clinical Reviewer, Precertification RN

Point32Health

. Perform clinical decision-making and utilization management for clinically complex service and coverage requests .

Posted 10/4/2026full-timeMassachusetts • United StatesMid-LevelSenior💰 $89,541 - $134,311 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical decision-making and utilization management, with a strong focus on medical necessity determination and compliance within regulatory frameworks. Possesses excellent communication skills for effective collaboration with healthcare providers and internal teams.

Highest-signal resume keywords

Registered Nurse LicenseUtilization Management ExperienceCritical Thinking SkillsClinical JudgmentManaged Care Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Decision-MakingMedical Necessity DeterminationUtilization ManagementCase ManagementQuality AssurancePolicy InterpretationAppeal Case ScreeningCoverage Document AnalysisClinical Guidelines ApplicationMedical Necessity Guidelines

Soft Skills

Problem SolvingOrganizational SkillsCustomer-Centered FocusInitiativeCreativity

Tools & Technologies

Multiple Software ApplicationsIMPACT Medical Systems

Certifications & Qualifications

Registered Nurse LicenseAssociate DegreeBachelor of Science in Nursing (Preferred)

Industry Keywords

Utilization Management TrendsManaged Care SettingComplianceRegulatory TimeframesClinical Experience

About the role

Key responsibilities & impact

Perform clinical decision-making and utilization management for clinically complex service and coverage requests
Determine medical necessity and benefit coverage using applicable coverage documents, clinical guidelines and Medical Necessity Guidelines
Ensure consistent and timely coverage decisions within product-specific compliance and regulatory timeframes
Collaborate with Medical Directors on denial determinations and standard business processes
Coach letter writers on appropriate medical necessity language for denial letters
Communicate with physicians, practices, facilities, allied health providers and external customers regarding determinations and case status
Orient new staff as needed
Interface between Precertification staff and providers on policy interpretation, access availability and quality assurance issues
Facilitate communication between Precertification and internal departments as a liaison or committee member
Provide input to the Medical Policy Department and IMPAC medical systems
Identify Utilization Management trends
Assist in screening appeal cases and provide clinical input
Model professionalism and leadership
Perform other projects and duties as assigned

Requirements

What you’ll need

Registered Nurse with a current and unrestricted Massachusetts license required
Associate Degree required (minimum)
BSN (Bachelor of Science in Nursing) preferred
Five years’ clinical experience in utilization management, case management or quality assurance required
Previous experience in a managed care setting
Highly developed critical thinking skills
Ability to investigate, evaluate and problem solve using sound clinical judgment and business knowledge
Ability to work in an extremely complex and fast-paced production environment
Skill in responding to inquiries from providers and/or members
Initiative and creativity in planning work
Ability to resolve cases correctly, effectively, expeditiously and within tight timeframes
Good organizational skills and a customer centered focus
Ability to use multiple software applications simultaneously
Excellent oral and written communication skills
Ability to work under normal office conditions and from home as required
Ability to adjust work schedule on short notice
May be required to work additional hours beyond standard work schedule

Benefits

Comp & perks

Medical, dental and vision coverage
Retirement plans
Paid time off
Employer-paid life and disability insurance with additional buy-up coverage options
Tuition program
Well-being benefits
Full suite of benefits to support career development, individual & family health, and financial health
Variable pay eligibility