Pre Certification RN

The Judge Group; United States; Remote; USD 51,143 - 72,840; Part time

Job summary

A recruitment agency is seeking a Pre-Certification RN to evaluate clinical conditions and determine medical necessity for services. This remote position requires an active RN license in PA or a Compact license, along with a minimum of 3 years of acute care clinical experience. Responsibilities include authorizing services, ensuring compliance with regulations, and acting as a patient advocate throughout the care process.

Qualifications

• Active RN license in PA or Compact license including PA.
• Minimum 3 years of acute care clinical RN experience in a hospital or healthcare setting.
• Prior discharge planning or utilization management experience preferred.

Responsibilities

• Review medical records to determine medical necessity using InterQual and medical policy criteria.
• Authorize services that meet established criteria; refer non-qualifying cases to the Medical Director.
• Communicate with providers to clarify treatment plans and medical needs.
• Ensure requests align with member benefit plans and regulatory requirements.
• Identify discharge planning needs and collaborate with case management staff.
• Maintain accurate documentation and meet turnaround time and productivity goals.
• Report utilization trends and quality-of-care issues as needed.

Skills

Clinical judgment

Communication skills

Detail-oriented

Education

Active RN license in PA or Compact license including PA

Job description

National Healthcare Recruiting Manager @ The Judge Group | Connecting top healthcare workers with their dream job

Pre-Certification RN

Location: Remote (must reside in PA, NJ, or DE)

Employment Type: Temporary with potential for permanent placement

Schedule: Monday–Friday, Day Shift

Pay: Up to $45/hour

Summary

The Pre-Certification RN evaluates members’ clinical conditions through medical record review to determine medical necessity for services. This role applies advanced clinical judgment, interacts with providers for additional information when needed, and authorizes medically necessary services. Cases not meeting criteria are referred to the Medical Director for further evaluation. The RN ensures compliance with federal, state, and accreditation regulations and acts as a patient advocate throughout the care process.

Key Responsibilities

• Review medical records to determine medical necessity using InterQual and medical policy criteria.
• Authorize services that meet established criteria; refer non-qualifying cases to the Medical Director.
• Communicate with providers to clarify treatment plans and medical needs.
• Ensure requests align with member benefit plans and regulatory requirements.
• Identify discharge planning needs and collaborate with case management staff.
• Maintain accurate documentation and meet turnaround time and productivity goals.
• Report utilization trends and quality-of-care issues as needed.

Qualifications

• Active RN license in PA or Compact license including PA.
• Minimum 3 years of acute care clinical RN experience in a hospital or healthcare setting.
• Prior discharge planning or utilization management experience preferred.