Outpatient Clinician, RN Reviewer

Point32Health

. Perform utilization management, medical necessity determinations and benefit determinations for clinically complex services and coverage requests .

Posted 9/21/2026full-timeRemote • Massachusetts • United StatesMid-LevelSenior💰 $89,541 - $134,311 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Medical Necessity Determinations, with strong critical thinking and problem-solving skills. Proficient in collaborating with healthcare providers and managing complex clinical cases within tight timeframes.

Highest-signal resume keywords

Registered Nurse LicenseUtilization ManagementClinical ExperienceCritical Thinking SkillsManaged Care Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity DeterminationsBenefit DeterminationsClinical Guidelines ApplicationCase ManagementQuality AssurancePolicy InterpretationAppeal Case ScreeningClinical JudgmentDocumentation SkillsTime Management

Soft Skills

Communication SkillsOrganizational SkillsProblem SolvingInitiativeCreativity

Tools & Technologies

IMPACT Medical SystemsMultiple Software Applications

Certifications & Qualifications

Registered Nurse LicenseAssociate Degree

Industry Keywords

Utilization Management TrendsPrecertificationManaged Care SettingClinical InputCustomer Centered Focus

About the role

Key responsibilities & impact

Perform utilization management, medical necessity determinations and benefit determinations for clinically complex services and coverage requests
Apply coverage documents, purchased clinical guidelines and Medical Necessity Guidelines consistently within product-specific timeframes
Collaborate with Medical Directors on denial determinations and ensure standard business processes are followed and documented
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 regarding policy interpretation, access availability and quality assurance issues
Facilitate communication between Precertification and internal departments as a liaison or committee member for new programs
Provide input to the Medical Policy Department on Medical Necessity Guidelines and purchased criteria through IMPAC medical systems
Identify Utilization Management trends in precertification and outpatient UM processes
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
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 adjust work schedule on short notice
Must be able to work under normal office conditions and work from home as required
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