RN Outpatient Reviewer, Precertification Operations

View full description

Requirements:

• Bachelor’s degree in Nursing preferred
• Registered Nurse with a current and unrestricted  Massachusetts license required

Responsibilities:

• Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations
• Collaborates with Medical Directors when determination to deny a request is indicated
• Coaches letter writers to assure that appropriate medical necessity language is clearly defined in the denial letter.
• Communicates frequently through the day with physicians, practices, facilities and/or allied health providers.
• Communicates frequently through the day with external customers (agents acting on behalf of the provider or member or both) regarding the rational for a determination, as well as the status and disposition of cases.
• Orients new staff to role as needed.
• Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.
• Facilitates communication between Precertification and other internal departments by acting as a liaison or committee member on the development or implementation of new programs.
• Provides input to the Medical Policy Department regarding the development of Medical Necessity Guidelines and adding input to purchased criteria through participation in the IMPAC.
• Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM processes.
• Assists in the screening of appeal cases to provide clinical input as needed or requested.
• Models professionalism and leadership in all capacities of the position to all audiences.