Clinical Utilization & Preauthorization Specialist

MCS Puerto Rico; San Juan (PR); On-site; USD 55,000 - 85,000; Full time

Job summary

MCS Puerto Rico is seeking a qualified registered nurse to conduct prospective reviews and determine appropriate levels of care based on clinical guidelines and medical necessity.

The role requires a Bachelor’s degree in Nursing Sciences, at least three years of healthcare experience, and an active Nurse & Association Nursing Professionals of Puerto Rico license. Fluency in Spanish and English at an intermediate level is expected in this position.

Qualifications

• Bachelor’s degree in Nursing Sciences.
• At least three (3) years of experience in a healthcare environment.
• A valid Nurse & Association Nursing Professionals of Puerto Rico License and Registration is required.

Responsibilities

• Offers guidance on the precertification process to clients and providers.
• Performs organizational and benefit determinations per regulatory requirements and timelines.
• Conducts prospective reviews of diagnostic studies, procedures, and equipment to assess medical necessity.
• Ensures client care aligns with service levels, using clinical guidelines to assess medical necessity.
• Obtains and evaluates required clinical information and communicates determinations to stakeholders.

Skills

Nursing

Education

Bachelor’s degree in Nursing Sciences

Job description

MCS Puerto Rico is seeking a qualified registered nurse to conduct prospective reviews and determine appropriate levels of care based on clinical guidelines and medical necessity.

The role requires a Bachelor’s degree in Nursing Sciences, at least three years of healthcare experience, and an active Nurse & Association Nursing Professionals of Puerto Rico license. Fluency in Spanish and English at an intermediate level is expected in this position.