NH Licensed Prior Authorization Nurse

Job Summary

Working remotely in a full-time capacity, the NH Licensed Prior Authorization Nurse will review proposed hospitalization and outpatient services for medical necessity, ensuring timely and appropriate care for members while adhering to established guidelines.

Key responsibilities:

• Determines medical appropriateness of services using evidence-based InterQual criteria and medical policies
• Performs utilization review activities, including pre-certification and concurrent reviews, and documents outcomes of these reviews
• Provides guidance to other utilization review nurses and participates in the orientation of newly hired staff

Required qualifications:

• Nursing degree or diploma required; Bachelor's degree preferred
• Active RN License in the state of NH or a compact eligible state that includes NH
• 2+ years of prior authorization experience and knowledge of evidence-based guidelines
• Managed care experience
• Ability to take after-hours calls, including evenings and weekends