Outpatient Clinician, RN Reviewer

Point32Health

. Manage a clinically complex caseload of varied service 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 Clinical Decision-Making, with a strong focus on Medical Necessity Determinations and Compliance within a Managed Care environment. Possesses excellent communication and organizational skills to effectively manage complex caseloads and collaborate with healthcare professionals.

Highest-signal resume keywords

Utilization ManagementMedical Necessity DeterminationsClinical ExperienceRegistered Nurse LicenseCritical Thinking Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ManagementMedical Necessity DeterminationsCase ManagementQuality AssuranceClinical JudgmentPolicy InterpretationAppeal ScreeningData AnalysisRegulatory ComplianceMedical Policy Input

Soft Skills

Critical ThinkingProblem SolvingOrganizational SkillsCommunication SkillsCustomer-Centered Focus

Tools & Technologies

IMPACT Medical SystemsMultiple Software Applications

Certifications & Qualifications

Massachusetts Registered Nurse License

Industry Keywords

Managed CareClinical GuidelinesPrecertificationHealthcare ComplianceService Requests

About the role

Key responsibilities & impact

Manage a clinically complex caseload of varied service requests
Perform utilization management, medical necessity determinations and benefit determinations using coverage documents, clinical guidelines and Medical Necessity Guidelines
Ensure consistent and timely coverage decisions within product-specific compliance and regulatory time frames
Collaborate with Medical Directors on denial determinations and 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 regarding policy interpretation, access availability and quality assurance issues
Facilitate communication between Precertification and internal departments on new program development or 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 screening appeal cases and provide clinical input
Model professionalism and leadership
Complete other projects and duties as assigned

Requirements

What you’ll need

Current and unrestricted Massachusetts Registered Nurse 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 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 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 from home as required
Ability to work additional hours beyond the standard work schedule when required

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