RN Utilization Management Reviewer

Job description

Ready to help us transform healthcare? Bring your true colors to blue. The Role: The Clinical Utilization Reviewer is responsible for facilitating care for members who may have complex healthcare needs, authorizing medically necessary services at the right level of care to promote optimal health. This position is self-directed and works independently and collaboratively to facilitate care using clinical skills, principles of managed care, nationally-recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member’s benefit to provide the best quality care. The Team: The Clinical Utilization Reviewer is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dieticians, pharmacist, clinicians, medical directors and more, who collaborate to facilitate care. This position is eligible for our eWorker, Mobile, and Resident personas. This position can be fully remote, with the expectation to work in our Hingham office 1x month. Key Responsibilities: Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilizat...