In this role, the nurse reviews prior authorization requests, evaluates medical necessity, and helps determine coverage for inpatient, outpatient, and post-acute services. The work centers on utilization management across Medicaid, Medicare, and commercial products, with regular collaboration with physicians and other healthcare providers. The position uses InterQual criteria and electronic health record tools in a remote or hybrid setting.
Key Responsibilities
- Conduct clinical reviews of prior authorization requests to assess medical necessity and coverage.
- Collaborate with physicians and healthcare providers to clarify clinical information and support review decisions.
- Assess inpatient, outpatient, and post-acute services using InterQual or similar criteria.
- Document review outcomes accurately and communicate decisions across multiple channels.
- Use electronic health records, Microsoft Office, and other healthcare software to support workflow efficiency.
- Analyze complex cases and apply clinical judgment to resolve utilization management questions.
- Stay current on managed care practices and different lines of business, including Medicaid, Medicare, and commercial plans.
Required
- Valid Registered Nurse license in Massachusetts.
- 2-4 years of experience in utilization management and managed care settings.
- Experience with InterQual or similar clinical review tools.
- Bachelor's degree in Nursing or a related healthcare field.
- Knowledge of Medicaid, Medicare, and commercial healthcare lines of business.
- Strong written and verbal communication skills.
Preferred
- Experience working in a remote or hybrid environment.
- Proficiency with Microsoft Office Suite and industry-specific healthcare applications.
- Background handling inpatient, outpatient, and post-acute review cases.
Benefits & Perks
- Remote or flexible hybrid work setting.
- Hourly pay range of $45-$50.
- Opportunity to work with clinical review tools and healthcare software in a managed care environment.