Outpatient Clinician RN Reviewer

Point32Health

. Perform clinical decision-making and utilization management 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 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

Massachusetts Registered Nurse LicenseUtilization Management ExperienceCritical Thinking SkillsExcellent Communication SkillsManaged 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 AssuranceClinical ScreeningPolicy InterpretationAdverse DeterminationsMedical Necessity GuidelinesTrend Identification

Soft Skills

Problem SolvingOrganizational SkillsCustomer-Centered FocusInitiativeCreativity

Tools & Technologies

IMPAC Medical SystemsMultiple Software Applications

Certifications & Qualifications

Registered Nurse LicenseAssociate DegreeBSN Preferred

Industry Keywords

Managed CareClinical GuidelinesCoverage RequestsComplianceRegulatory Timeframes

About the role

Key responsibilities & impact

Perform clinical decision-making and utilization management for clinically complex services 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 adverse determinations and document process variances
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
Liaise between Precertification staff and providers on policy interpretation, access availability and quality assurance issues
Facilitate communication between Precertification and internal departments on new program development and implementation
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 with clinical screening of appeal cases
Model professionalism and leadership
Perform other assigned projects and duties

Requirements

What you’ll need

Current and unrestricted Massachusetts Registered Nurse license required
Associate Degree required
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 and resolving 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
Ability to work under normal office conditions and work from home as required
Ability to use a telephone/headset and PC/keyboard simultaneously and sit for extended durations
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