Job Description

Note: Candidates must be RN licensed in Massachusetts.



Job Summary

The Clinical Reviewer is a licensed professional –a Registered Nurse preferred– that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for making the determination of medical necessity and, therefore, benefit coverage for multiple products / lines of business; such as state specific Medicaid and Senior Products (Medicare Advantage and SCO).

The Clinical Reviewer ensures consistent and timely disposition of coverage decisions as required by product specific compliance and regulatory time frames. The Clinical Reviewer functions as a member of the Precert / Outpatient UM team and works under the general direction of the Precertification Team Manager or department Manager. The Clinical Reviewer is expe...