Massachusetts Licensed RN Reviewer

Managing a clinically complex caseload, the full-time Massachusetts Licensed RN Reviewer will determine medical necessity and benefit coverage for members, ensuring timely decisions while working remotely. Key responsibilities: Perform utilization management and medical necessity determinations for service requests within established time frames Collaborate with Medical Directors on denial requests and coach staff on appropriate medical necessity language in denial letters Facilitate communication between Precertification staff and providers, ensuring timely coverage decisions and addressing policy interpretation issues Required qualifications: Current and unrestricted Massachusetts Registered Nurse license Associate Degree in Nursing required; BSN preferred Minimum of five years' clinical experience in utilization management, case management, or quality assurance Experience in a managed care setting is preferred Highly developed critical thinking skills and ability to work in a fast-paced environment