Remote Prior Authorization Clinician (RN)

WellSense Health Plan; New Hampshire; À distance; USD 49 000 - 71 000; Plein temps

Avantages offerts par ce poste

Medical benefits

Dental benefits

Vision benefits

403(b) match

Paid time off

Flexible Spending Accounts

Résumé du poste

WellSense Health Plan is seeking a Prior Authorization Clinician to review proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency to ensure timely, appropriate care for members.

The role requires RN licensure in NH or a compact state, 2+ years of prior authorization experience with InterQual guidelines, and managed care knowledge. This is a fully remote position with potential travel to the Charlestown, MA office for meetings.

Qualifications

• 2+ years prior authorization experience with InterQual guidelines.
• Managed care knowledge.

Responsabilités

• Determines medical appropriateness of inpatient and outpatient services following evaluation of guidelines.
• Performs utilization review activities including pre-certification, concurrent and retrospective reviews.
• Determines medical necessity by applying criteria to first level reviews and using approved guidelines.
• Communicates review outcomes and inquiries to providers and members.
• Refers cases to Physician Reviewer when not meeting medical necessity or when guidelines are unavailable.
• Sends system-generated letters to provider and member.
• Guides and coaches other utilization review nurses.
• Documents rate negotiation for proper claims adjudication.
• Identifies opportunities for improved communication or processes.
• Maintains compliance with Federal, State and accreditation organizations.

Connaissances

Prior authorization experience

InterQual guidelines

Managed care knowledge

Remote work capability

Formation

RN license NH or compact state (NH)

Outils

Microsoft Office

Description du poste

WellSense Health Plan is seeking a Prior Authorization Clinician to review proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency to ensure timely, appropriate care for members.

The role requires RN licensure in NH or a compact state, 2+ years of prior authorization experience with InterQual guidelines, and managed care knowledge. This is a fully remote position with potential travel to the Charlestown, MA office for meetings.