Massachusetts Licensed Prior Authorization Clinician

Job Summary

Working remotely on a contract basis, the Massachusetts Licensed Prior Authorization Clinician will review inpatient, outpatient, and home care service requests for medical necessity, utilizing evidence-based guidelines while ensuring compliance with various regulatory standards.

Key responsibilities

• Review clinical documentation and determine medical necessity for requested services
• Perform prior authorization, utilization review, and retrospective reviews while documenting outcomes
• Ensure compliance with Medicaid, ACA, CMS, and NCQA turnaround requirements

Required qualifications

• Active and unrestricted RN license in MA, NH, or a compact state
• Nursing degree/diploma required; BSN preferred
• 2+ years of prior authorization/utilization review experience
• Experience with InterQual and evidence-based guidelines
• Knowledge of Medicare and Medicaid preferred