26 Results for

Clinical Reviewer Jobs in Massachusetts

Jobs

Canton, MA30+ days ago

$60–$61 Per Hour

Key Responsibilities/Duties – what you will be doingProvides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames. Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.

Canton, MA30+ days ago

$50–$50 Per Hour

Key Responsibilities/Duties – what you will be doing:Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames. Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.

Westborough, Massachusetts20 days ago

Remote

Under the general supervision of the Associate Director, or designee, the Clinical Reviewer - PASRR is responsible for reviewing submitted referrals and any accompanying clinical documentation to the Pre-Admission Screening and Resident Review (PASRR) unit for completeness. Ability to understand and utilize resources for problem solving, in order to deal with problems involving multiple variables, effectively prioritizing and executing tasks in a high pressure, fast paced environment.

Westborough, MA19 days ago

Remote

Canton, MA30+ days ago

$81,217.85–$121,826.77 Per Year

The BH UM Clinician works collaboratively with the Behavioral Health leadership within the Behavioral Health department and other appropriate Point32Health staff to identify and address opportunities to improve service, reduce administrative cost, ensure clinically appropriate delivery of benefit covered services, and support department and organizational business goals. Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes: Medical, dental and vision coverage Retirement plans Paid time off Employer-paid life and disability insurance with additional buy-up coverage options Tuition program Well-being benefits Full suite of benefits to support career development, individual & family health, and financial health.

MA30+ days ago

$26.01–$74.78 Per Year

Application of critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Westborough, Massachusetts26 days ago

Under the general supervision of the Associate Director, or designee, the Nurse Reviewer II is responsible for completing in-person assessments and reviewing supporting documentation to determine clinical eligibility for individuals who are residing in the community receiving services through the Family Assistance Pathway. • Maintain positive working relationships with members, and relevant formal/informal supports, provider organizations, program consultants and state agencies.

New!

Boston, MAToday

The QA Reviewer/Analyst, under the direction of the Director, is responsible for identifying and mitigating risk of denials to the Department and ensuring highest quality of work by the Admissions Counselors via daily management of Patient Access EPIC WQs (Patient/Account/Claims); weekly review of the in-house high dollar Ontrac accounts; monitoring of DFCI patients in BWH beds; oversight of denials in conjunction with Department Team Leads and Manager, among other responsibilities aimed at improving the financial healthof the Department overall. Will assist Team Leads and Manager in reviewing Ontrac exceptions and tracking KPI and meeting Department expectations, e.g., elective teams days out, urgent team completed post discharge metrics.

Boston, MA30+ days ago

As Physician Reviewer/Advisor you will utilize clinical expertise and reviews insurance appeals, and prospective and retrospective claims.

New!

Boston, MA1 day ago

Remote

Part-time

With a global footprint across four continents, MMS not only maintains an industry-leading customer satisfaction rating but also fosters a collaborative and inclusive work environment where employees can thrive. Responsible for strategies in pre and post marketing risk management, as well as keeping abreast of pharmacovigilance methods and trends in published literature and global regulations.

Cambridge, MA30+ days ago

$110–$120 Per Hour
Full-time

Summary of Key Responsibilities: Perform daily medical review and causality assessment of ICSRs in accurate, consistent, and timely manner to contribute to continuous signal detection and management process Collaborate with other pharmacovigilance colleagues to align on a harmonized approach to identifying, evaluating and communicating safety issues Identify topics for escalation and collaborate with safety product leads to investigate potential safety signals Collaborate with GPSRM Quality and Case Management teams to identify case review issues and inconsistency and work on addressing these issues under the leadership of Head of Medical Review Participate in process improvements for the Medical Review team Maintain close communication with the case processing and medical case review vendors Qualifications: There is a strong pipeline, significant resources, and every intention of continuing the phenomenal rate of success and growth. The ideal candidate will have the following mix of personal and professional characteristics: Medical Degree with a minimum of 1 year of medical practice is required Must have a minimum of 2 years of pharmaceutical industry experience within pharmacovigilance or clinical research Experience in medical case review is a strong plus Sound clinical acumen and a wide range of therapeutic area knowledge.

New!

Cambridge, MA4 days ago

$139.86–$145 Per Hour

Accountabilities Oversight of global medical review of individual case safety reports for Client investigational and marketed products from all sources includes but not limited to the following: seriousness criteria confirmation and expectedness/listedness assessment review of the reporter s causality and company causality assessment event confirmation and coding as per convention, analysis of similar events as required, provide sound rationale in Company. Proven ability to work in international environment and with cross-functional teams, with good interpersonal skills / assertiveness / team spirit / coaching skills.

New!

Athol, Massachusetts5 days ago

$38–$57.48 Per Hour

Works collaboratively with a multidisciplinary team to determine each patient's needs concurrently including post-acute care when needed; addresses LOS issues, appropriate leveling of patient status; addresses potential needs, resources, referrals for other disciplines etc. Responsible for completing nursing sections of the SNF Level of Care forms for Mass Health patients in need of care, SNF placement, timely and efficiently and other forms assisting in transition of care as identified and collaborates with the social worker.

Westborough, Massachusetts30+ days ago

Under the general direction of the Associate Director, or designee, the Clinical Coordinator is responsible to develop, prioritize, and oversee staff activities specifically designed to promote the coordination of care for those MassHealth members who have medically complex, chronic or catastrophic illnesses that require a customized approach to how, when, and where they receive medically necessary health care services. 3 years of related work experience with prior authorization and/or eligibility determinations for disabled, medically complex, home care, rehab or long term care populations strongly preferred.

Springfield, MA30 days ago

Remote

$89,606–$103,001 Per Year

The UM Inpatient Clinical Review Nurse contributes to the overall success of the Utilization Management department by performing clinical reviews for inpatient, including determining the members overall health, reviewing the type of care being delivered, and evaluating medical necessity, in compliance with governing regulations, internal policies, and procedures. Performs pre-service, concurrent, and retrospective reviews of members for appropriate care and setting to determine overall health and appropriate level of care, using applicable coverage documents and clinical guidelines.

Boston, MA7 days ago

$38–$48

Through innovative home- and community-based services, Vitra supports aging adults, people with disabilities, and individuals with complex care needs— supported by a Nurse, and Case Manager, Vitra ensures clients receive compassionate, personalized, and dignified care. Requires lifting and carrying equipment and supplies weighing up to 35 pounds; requires pushing and pulling equipment and supplies weighing up to 35 pounds; requires walking and standing; requires frequent sitting more than 75% of the workday; requires the ability to navigate stairs; requires visual acuity and manual dexterity to operate equipment. .

New!

Charlestown, MA, MA3 days ago

Remote

Experience: " 2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines) " Managed care experience " Experience performing discharge planning " All employees working remotely will be required to adhere to Wellenses Telecommuter Policy Licensure, Certification or Conditions of Employment: Active, unrestricted RN license in state of residence Pre-employment background check Ability to take after hours call, including evening/nights/weekends Competencies, Skills, and Attributes: Strong oral and. The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes.

New!

Charlestown, MA2 days ago

Remote

$50–$55 Per Hour

2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines) Managed care experience Experience performing discharge planning All employees working remotely will be required to adhere to Wellenses Telecommuter Policy Licensure, Certification or Conditions of Employment: Active, unrestricted RN license in state of residence Pre-employment **** Ability to take after hours call, including evening/nights/weekends Competencies, Skills, and Attributes: Strong oral and. The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes.

New!

Charlestown, MA, MA3 days ago

Remote

$50–$55 Per Hour

2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines) " Managed care experience " Experience performing discharge planning " All employees working remotely will be required to adhere to Wellenses Telecommuter Policy Licensure, Certification or Conditions of Employment: Active, unrestricted RN license in state of residence Pre-employment **** Ability to take after hours call, including evening/nights/weekends Competencies, Skills, and Attributes: Strong oral and. The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes.

Gardner, Massachusetts30+ days ago

$38–$57.48 Per Hour

Quality & Statistical Data: Reviews medical record for abnormal findings,complications, delays and deviations from expected clinical outcomes reports such to Provider and/or Director to maintain an efficient, cost effective episode of care for each patient and documents intervention provided. Organizational ExpectationsBehavioral Attributes:The following behavioral attributes are required: achievement motivation, flexibility, concern for order, initiative, self-confidence, self control, customer service orientation, interpersonal effectiveness, teamwork and information seeking.

Springfield, MA30+ days ago

$118,934–$136,718 Per Year

This system-wide Nurse Excellence Programs Strategist partners with nursing leadership, shared governance councils, and frontline nurses to cultivate a professional practice environment grounded in exemplary professional practice, transformational leadership, structural empowerment, new knowledge and innovations, quality, safety, well-being, and empirical nursing outcomes. Under the general direction of the System Director of Nursing Excellence, the Nurse Excellence Programs Strategist serves as a key strategic leader responsible for advancing systemwide professional nursing excellence through the successful achievement and sustainment of ANCC Magnet®, Pathway to Excellence®, and Practice Transition Accreditation Program (PTAP) designations.

Springfield, MA30+ days ago

This system-wide Nurse Excellence Programs Strategist partners with nursing leadership, shared governance councils, and frontline nurses to cultivate a professional practice environment grounded in exemplary professional practice, transformational leadership, structural empowerment, new knowledge and innovations, quality, safety, well-being, and empirical nursing outcomes. Summary: Under the general direction of the System Director of Nursing Excellence, the Nurse Excellence Programs Strategist serves as a key strategic leader responsible for advancing systemwide professional nursing excellence through the successful achievement and sustainment of ANCC Magnet®, Pathway to Excellence®, and Practice Transition Accreditation Program (PTAP) designations.

New!

Waltham, MA5 days ago

$272,000–$340,000 Per Year

Provide practical legal advice on pre-launch activities and launch strategy, including medical (e.g., MSL activities and programs), disease awareness, sales, marketing (brand messaging, activities and campaigns), marketing analytics, patient advocacy programs, advisory boards, incentive compensation for commercial personnel and other business activities. Zenas' earlier stage programs include ZB021, a clinical-stage, potentially best-in-class, oral, IL-17AA/AF inhibitor; ZB022, a preclinical, potentially best-in-class, oral, brain-penetrant, TYK2 inhibitor; and ZB014, a preclinical half-life extended anti-CD-19 and FcRIIb monoclonal antibody.

New!

Cambridge, MAToday

$185,000–$260,000 Per Year

This is a highly visible role working cross‑functionally with Clinical Development, Biostatistics, Statistical Programming, Regulatory, Quality, and external partners to ensure data integrity, inspection readiness, and timely delivery of data supporting key development and regulatory milestones. Beam's suite of gene editing technologies is anchored by base editing, a proprietary technology that is designed to enable precise, predictable and efficient single base changes, at targeted genomic sequences, without making double-stranded breaks in the DNA.

New!

Quincy, MA5 days ago

Registered Nurse III'',''Registered Nurse III'',''United States-Massachusetts-Quincy - 100 Hancock Street'',''United States-Massachusetts-Quincy - 100 Hancock Street'',''Medical Services'',''Medical Services'',''Exec Office Of Health and Human Services'',''Exec Office Of Health and Human Services'',''Full-time'',''Full-time'',''Day'',''Day'',''Jun 2, 2026, 7:29:56 PM'',''Jun 2, 2026, 7:29:56 PM'',''1'',''1'',''150,686.38'',''90,304.24'',''150,686.38'',''Yearly'',''Stacy Hart / Stacy. Providing clinical support to OLTSS program teams in the day-to-day management of their programs, in the form of reviewing critical incident reports, advising on quality improvement and performance measurement initiatives, responding to providers on clinical issues, assisting with hard-to-place MassHealth members, and advising on clinical impact of changes to regulations and medical necessity criteria.

New!

Watertown, MAToday

$160,000–$240,000 Per Year

Having advanced the first degrader into the clinic for immunological diseases, Kymera is focused on building an industry-leading pipeline of oral small molecule degraders to provide a new generation of convenient, highly effective therapies for patients with these conditions. Deep understanding of small molecule drug development; understand how CMC disciplines integrate and partner with associated functional areas such as Quality, Non-clinical Safety, Clinical, Regulatory, and Intellectual Property Protection.

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Clinical Reviewer Jobs in Massachusetts

Clinical Reviewer Utilization Management Registered Nurse # 26-07418 US Tech Solutions, Inc.

Clinical Reviewer Outpatient Registered Nurse # 26-10731 US Tech Solutions, Inc.

Clinical Reviewer - PASRR University of Massachusetts Medical School

Clinical Reviewer PASRR UMass Chan Medical School

Clinical Reviewer, BH outpatient services Point32Health, Inc.

Prior Authorization Clinical Reviewer CVS Health Corp

Nurse Reviewer II-LOC University of Massachusetts Medical School

Prior Authorization Trainer/QA Reviewer - Inpatient Accounts - Hybrid schedule Phenom People

Board Certified-(M.D, D.O) Boston Family Practice Record Reviewer Dane Street

Cardiology Medical Reviewer (Project-Based) - Remote MMS

Medical Reviewer LanceSoft Inc

Director, Medical Reviewer LanceSoft Inc

RN Clinical Coordinator, Case Management, 32-Hours, Days, No Weekends or Holidays Athol Hospital

Clinical Coordinator University of Massachusetts Medical School

UM Inpatient Clinical Review Nurse Baystate Health System

Telehealth Nurse (4-Day Work Week on site) VITRA Health

Inpatient UM Clinician Integrated Resources, Inc

Inpatient UM Clinician Axelon

Inpatient UM Clinician Axelon Services Corporation

RN Care Coordinator, Case Management, 8-Hours, Mornings, Weekends, 4 hour shifts on Saturdays and Sundays Heywood Hospital

Nurse Excellence Programs Strategist Baystate Health

Nurse Excellence Programs Strategist Baystate Health System

Vice President, Legal - Lead Commercial Counsel Zenas BioPharma (USA) LLC

Associate Director / Director, Data Management Beam Therapeutics

Registered Nurse III Commonwealth of Massachusetts

Principal Scientist/Associate Director, Process Chemistry Kymera Therapeutics

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