The Clinical Reviewer is a licensed professional – RN – 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 Commercial (FI, SI and exchange products), 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 expected to demonstrate the ability to work independently as well as collaboratively within a team environment. The Clinical Reviewer will be expected to demonstrate sound clinical and health plan business knowledge in their decision making processes, on behalf of the health plan.

EDUCATION:  

• Bachelor's degree in Nursing, Physical Therapy, Physiatry or other related field preferred
• Registered Nurse or Physical Therapist with current a and unrestricted  Massachusetts license required

EXPERIENCE:   

• Minimum of five years clinical experience in utilization management, case management or quality assurance preferred
• Previous experience in a managed care setting desirable

SKILL REQUIREMENTS:  

• Requires an individual with highly developed critical thinking skills and the ability to investigate, evaluate and problem solve using sound clinical judgment and business knowledge.
• Requires the ability to work in an extremely complex and potentially politically charged environment.
• Demonstrated skill in responding to inquiries from providers and/or members
• Must exhibit initiative and creativity in planning of work and be able to resolve cases correctly, effectively, expeditiously and within tight timeframes.
• Good organizational skills and a customer centered focus required.
• Individual must be able to use multiple software applications/ computer literate.
• Excellent oral and written communication skills required.