Pennsylvania Licensed Precertification RN

Job Summary

To support healthcare operations, the remote part-time Pennsylvania Licensed Precertification RN will evaluate members' clinical conditions through medical record reviews, determine medical necessity for services, and interact with providers to obtain additional clinical information.

Key Responsibilities

• Applies critical thinking and advanced medical knowledge to assess cases and make determinations on medical necessity
• Utilizes resources such as InterQual and medical policies to evaluate treatment plans and clarify medical needs with providers
• Collaborates with case management staff to facilitate appropriate discharge planning and reports utilization trends to management

Required Qualifications

• Active Pennsylvania RN license or compact including Pennsylvania
• Experience with precertification or prior authorization processes
• Experience in Home Health, Hospice, Durable Medical Equipment, or elected procedures
• Preferred experience with InterQual criteria
• Must reside in Pennsylvania, Delaware, or New Jersey