Remote Prior Authorization RN – Utilization Review

Mindlance; United States; On-site; USD 85,000 - 110,000; Full time

Job summary

Mindlance is seeking an Outpatient Prior Authorization Registered Nurse (RN) to conduct clinical utilization management reviews for Medicare, Medicaid, and Dual Eligible populations. You will evaluate outpatient service requests against medical necessity criteria and regulatory guidelines to ensure timely access to care while supporting a remote, collaborative team.

Responsibilities include clinical review and determination, documentation for compliance, queue management, and communication with

Qualifications

• Education: Graduate of an accredited School of Nursing.
• Licensure: Active, unrestricted Compact (NLC) RN license.
• Clinical Experience: Minimum of 2 years of direct clinical nursing experience.

Responsibilities

• Clinical Review & Determination: Evaluate outpatient prior authorization requests using clinical judgment and evidence-based criteria to determine medical necessity.
• Queue & Case Management: Manage daily assignments and work queues to complete reviews within mandated turnaround times.
• Documentation & Compliance: Document findings and rationale in compliance with Medicare/Medicaid regulations and quality standards.
• Collaborative Communication: Interface with healthcare providers and internal teams to gather necessary clinical details and resolve inquiries.
• Performance Standards: Maintain productivity expectations (~1.85 reviews per hour) with high quality and accurate documentation.

Education

Graduate of an accredited School of Nursing

Active, unrestricted Compact (NLC) RN license

Job description

Mindlance is seeking an Outpatient Prior Authorization Registered Nurse (RN) to conduct clinical utilization management reviews for Medicare, Medicaid, and Dual Eligible populations. You will evaluate outpatient service requests against medical necessity criteria and regulatory guidelines to ensure timely access to care while supporting a remote, collaborative team.

Responsibilities include clinical review and determination, documentation for compliance, queue management, and communication with