Pre-Authorization Registered Nurse

This is a fully remote position, open to applicants in Florida, +6 more states.

📋 Description

• Evaluate prior authorization requests to ensure appropriate care and setting.

• Adhere to guidelines and policies to either approve services or escalate requests to the relevant stakeholder.

• Conduct medical necessity and level-of-care assessments for requested services utilizing clinical judgment.

• Refer cases to internal stakeholders for additional review based on findings.

• Provide education to providers on utilization and medical management procedures.

• Input and maintain relevant clinical data in medical management systems.

• Analyze departmental, segment, and organizational strategies along with operating objectives.

• Make informed decisions regarding work methods in situations that may be unclear.

• Operate with minimal supervision while adhering to established guidelines and procedures.

⛳️ Requirements

• Current Licensed Registered Nurse (RN) in Virginia or eligible for a license in a state participating in the compact license (eNLC) with no disciplinary actions.

• At least two years of diverse clinical nursing experience in acute care, skilled, or rehabilitation settings.

• Prior experience in utilization management, case management, discharge planning, and/or home health or rehabilitation.

• Intermediate to advanced proficiency in Microsoft Office applications including Word, Excel, and PowerPoint.

• Ability to navigate various systems and platforms effectively.

• Capacity to troubleshoot and resolve basic technical issues in a remote setting.

• Ability to work independently under general supervision as well as collaboratively within a team.

• Availability to work 8 hours from Monday to Friday between 8:00 AM and 5:00 PM Eastern Time.

• May be required to work rotating holidays or weekends based on business requirements.

• Minimum home internet connectivity of 25 Mbps download and 10 Mbps upload.

• Designated workspace free from ongoing interruptions to safeguard member PHI/HIPAA information.

• Preferred: Experience in health plans working with large insurance carriers.

• Preferred: Prior experience with Medicare/Medicaid.

• Preferred: Certification in Case Management (CCM) or Managed Care Nursing (CMCN).

• Preferred: Familiarity with MCG or InterQual guidelines.

🏝️ Benefits

• Bonus incentive plan based on both company and individual performance.

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• 401(k) retirement savings plan.

• Paid time off.

• Company holidays.

• Personal holidays.

• Paid parental leave.

• Paid caregiver leave.

• Short-term disability coverage.

• Long-term disability coverage.

• Life insurance benefits.

• Wellness programs and smart healthcare decision support.

• Opportunity for remote work from home.

• Occasional travel for training or meetings.