Wisconsin Licensed RN Consultant

Job Summary

Leveraging clinical expertise, the fully remote Wisconsin Licensed RN Consultant will review Medicaid prior authorization requests, determine medical necessity, and collaborate with providers and internal stakeholders to ensure high-quality healthcare services.

Key responsibilities

• Review and adjudicate prior authorization requests based on medical necessity and eligibility requirements
• Summarize clinical information and render authorization decisions, including approvals, modifications, and denials
• Provide education and support to the provider community regarding authorization requirements and submissions

Required qualifications

• Active RN license in the State of Wisconsin
• Experience reviewing prior authorizations and applying medical necessity criteria
• Knowledge of Medicaid programs and healthcare policy guidelines
• Strong clinical assessment and critical thinking skills
• Ability to interpret clinical documentation and make sound coverage determinations