Clinical Reviewer Outpatient Utilization Management RN

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com. US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Duration: 4 months Contract (with the possibility of extension) Employment type : W2 License: Unrestricted Massachusetts Registered Nurse (RN) License Required Job Summary: The Clinical Reviewer is a licensed professional (RN preferred) responsible for independently managing a complex caseload of service requests. They determine medical necessity and benefit coverage for Medicaid, Medicare Advantage, and other products. The role requires adherence to compliance guidelines, timely decisions, and collaboration with Precertification and Outpatient Utilization Management teams.

Perform clinical decision-making for utilization management and benefit determinations. Collaborate with Medical Directors on denials and ensure adherence to processes. Communicate with providers, members, and external agents on case status and determinations. Assist in policy interpretation and quality assurance. Identify trends in utilization management and support appeals processes. Provide input for medical policy development and guidelines. Support onboarding and training of new staff.