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Clinical Reviewer RN
2 months ago
Key Responsibilities
Manage a clinically complex caseload for service requests and make determinations of medical necessity
Collaborate with Medical Directors on denial requests and ensure compliance with established processes
Facilitate communication between Precertification staff and providers regarding policy interpretation and coverage decisions
Required Qualifications
Bachelor's degree in Nursing preferred
Current and unrestricted Registered Nurse license in Massachusetts required
Minimum of five years clinical experience in utilization management, case management, or quality assurance preferred
Previous experience in a managed care setting desirable
