Remote UM - Prior Authorization RN

We are seeking an experienced and dedicated Registered Nurse (RN) to join our team as a Utilization Management Specialist. In this role, you will review prior authorization requests, assess clinical needs against established guidelines, and collaborate with multidisciplinary care teams to ensure quality, cost-effective care and appropriate levels of service.

Responsibilities

• Review prior authorization requests for medical necessity, appropriateness of care, and compliance with established clinical guidelines, policies, and regulatory requirements.
• Assess the appropriate level of care, service, treatment, and length of stay to support authorization determinations.
• Evaluate clinical documentation and collaborate with providers to obtain additional information when needed.
• Process authorization requests accurately and within established turnaround times.
• Coordinate with physicians, facilities, vendors, and internal departments to facilitate timely authorization decisions and continuity of care.
• Monitor and coordinate out-of-network and out-of-area services in accordance with plan policies and benefit guidelines.
• Educate providers and members regarding authorization requirements, coverage criteria, and available resources.
• Identify cases requiring physician review and ensure appropriate escalation according to established procedures.
• Document reviews, determinations, and communications accurately and comprehensively in designated systems.
• Promote quality, cost-effective care through the consistent application of evidence-based clinical criteria and utilization management principles.

Qualifications

• License: Active NJ RN License or Compact RN license.
• Experience: Minimum of 2 years of Utilization Management experience with a focus on prior authorization working for a health plan.
• Technical Skills: Proficiency with Microsoft Office applications, including Word, Excel, PowerPoint, Outlook, and general computer proficiency.
• Core Competencies: Working knowledge of utilization management; strong clinical assessment skills against established guidelines; excellent documentation, time management, and organizational abilities.
• Communication: Ability to work independently while effectively communicating with multidisciplinary teams.
• Location: Candidate must reside in NJ, PA, NY, CT, or MD.

Comprehensive benefits are available for qualified candidates. Medical, dental, and vision insurance are available to qualified candidates who meet eligibility requirements.

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