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Nurse Reviewer - REMOTE - Job Opportunity at University of Massachusetts Medical School

Shrewsbury, US
Full-time
Mid-level
Posted: February 28, 2025
Remote
USD 75,000 - 95,000 per year based on Massachusetts market rates for clinical review positions and required experience level

Benefits

Healthcare benefits typical of academic medical institutions
Professional development opportunities
Academic environment advantages
Work-life balance through remote work arrangement

Key Responsibilities

Clinical decision-making for prior authorization requests based on MassHealth guidelines
Multi-disciplinary care coordination and assessment
Provider and stakeholder relationship management
Quality assurance and compliance oversight
Appeals process management and documentation
Performance improvement initiatives participation

Requirements

Education

Bachelor's degree in Nursing/OT or Master's degree in SW; OR LPN certification

Experience

RN/OT/SW: 3 years in home health care or case management; LPN: 6 years clinical nursing experience

Required Skills

Clinical assessment expertise Excellent oral and written communication Time management/organizational skills Independent work capability Team collaboration Adaptability in complex environments

Certifications

RN, OT, SW license in Massachusetts OR LPN license in Massachusetts
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Sauge AI Market Intelligence

Industry Trends

Healthcare utilization management is experiencing significant growth due to cost containment pressures in the US healthcare system Remote clinical review positions are becoming increasingly prevalent as healthcare organizations embrace digital transformation Prior authorization processes are becoming more automated, requiring reviewers to develop stronger technical competencies

Role Significance

Typically part of a 10-15 person review team within larger healthcare management structure
Mid-level position with significant autonomous decision-making authority in clinical determinations

Key Projects

Implementation of new clinical review guidelines Process improvement initiatives for authorization workflows Quality assurance program participation Provider education and relationship management

Success Factors

Strong clinical judgment combined with regulatory knowledge Ability to balance efficiency with thorough assessment Excellence in stakeholder communication and relationship management Adaptability to evolving healthcare policies and guidelines

Market Demand

High demand with steady growth projected due to increasing focus on healthcare cost management and regulatory compliance

Important Skills

Critical Skills

Clinical assessment expertise for accurate medical necessity determinations Regulatory compliance knowledge for adherence to MassHealth guidelines Communication skills for stakeholder management

Beneficial Skills

Healthcare technology proficiency Quality improvement methodologies Healthcare policy understanding

Unique Aspects

Combination of clinical expertise with regulatory compliance focus
Remote work opportunity in traditionally on-site healthcare sector
Direct impact on healthcare access and utilization in state system

Career Growth

2-4 years in role typical before advancement to management positions

Potential Next Roles

Clinical Review Manager Utilization Management Director Healthcare Quality Manager Clinical Operations Director

Company Overview

University of Massachusetts Medical School

Leading academic medical institution with strong reputation in healthcare education and research

Prominent position in Massachusetts healthcare system with significant influence on state healthcare policies
Major employer in New England healthcare sector with strong academic and clinical partnerships
Professional academic environment with emphasis on evidence-based practice and continuous learning
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