Massachusetts Licensed Prior Authorization RN

Job Summary

A company is looking for a Prior Authorization Clinician (RN).

Key Responsibilities

• Evaluate service requests for medical necessity using clinical guidelines
• Conduct utilization reviews and document all activities accurately
• Communicate determinations effectively with stakeholders and escalate cases as needed

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license in state of residence
• Minimum of 2+ years of prior authorization or utilization review experience
• Experience applying evidence-based clinical guidelines
• Strong clinical judgment and critical thinking skills
• Solid understanding of Medicare, Medicaid, and/or commercial health plan structures