Clinical Utilization Reviewer

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.

Key Responsibilities

• Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service.
• Evaluate members’ clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care.
• Pass annual InterQual Interrater Reliability Test.
• Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care.
• Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues.
• Understand member insurance products and benefits, as well as regulatory and NCQA requirements.

Key Qualifications

• Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team.
• Ability to assess, analyze, draw conclusions, and construct effective solutions.
• Proficient with multiple IT systems.
• Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.

Education and Experience

• 3-5 years relevant experience in a variety of appropriate clinical health care settings (Inpatient, outpatient, or differing levels of care).
• Utilization Management experience, preferred.
• Active licensure in Massachusetts is required, appropriate to position (RN).

Licensure in additional states a plus

• Note: Any restrictions against a license must be disclosed and reviewed.
• For Registered Nurses Only: A Bachelor’s degree in nursing (BSN) is preferred.

Minimum Education Requirements

• High school degree or equivalent required unless otherwise noted above.