Massachusetts Licensed Clinical Reviewer

Job Summary

A company is looking for a LPN/OTA/PTA Clinical Utilization Management Reviewer.

Key Responsibilities:

• Conducts timely clinical decision reviews for services requiring prior authorization across various clinical areas
• Applies established criteria to interpret clinical guidelines and determine the medical necessity of services
• Communicates review results to the primary care team, specialty providers, and members while ensuring compliance with regulatory requirements

Required Qualifications, Training, and Education:

• Associates Degree
• Current Massachusetts LPN, OTA, or PTA clinical license in good standing
• 3+ years of combined clinical and utilization management/care management experience
• Home Health experience required
• Experience working in a health plan or with a care management platform is a strong plus