NH Licensed Prior Authorization Nurse

Job Summary

To ensure members receive appropriate and timely care, the full-time remote NH Licensed Prior Authorization Nurse will review hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency, utilizing evidence-based guidelines.

Key responsibilities:

• Determines medical appropriateness of services using InterQual criteria and medical policies
• Performs utilization reviews, including pre-certification and concurrent reviews, according to established guidelines
• Communicates outcomes of utilization reviews and refers cases to Physician Reviewers when necessary

Required qualifications:

• Nursing degree or diploma required
• Active RN License in the state of NH or a compact eligible state that includes NH
• 2+ years of prior authorization experience with evidence-based guidelines
• Managed care experience preferred
• Knowledge of Medicare and Medicaid is desirable