Remote RN Prior Authorization Clinician – Utilization Review

WellSense Health Plan; United States; Remote; USD 49,000 - 71,000; Full time

Benefits offered by this job

Full-time remote work

Competitive salaries

Excellent benefits

Job summary

WellSense Health Plan is seeking a Prior Authorization Clinician for a fully remote role in the United States. You will review inpatient and outpatient requests for medical necessity using InterQual criteria and relevant policies to ensure timely, appropriate care for members.

The position requires an active RN license (NH or compact with NH) and prior authorization experience. Strong communication and decision-making skills are essential, with some travel to the Boston area possible for

Qualifications

• Nursing degree or diploma required.
• Active RN License in NH or a compact state that includes NH.
• Experience with InterQual guidelines or similar evidence-based criteria.

Responsibilities

• Determines medical appropriateness of inpatient and outpatient services using InterQual criteria and policy.
• Performs utilization review including pre-certification, concurrent and retrospective reviews.

Skills

Oral communication

Written communication

Clinical judgement

Remote work

Education

Nursing degree or diploma

Tools

Microsoft Office

Data management systems

Job description

WellSense Health Plan is seeking a Prior Authorization Clinician for a fully remote role in the United States. You will review inpatient and outpatient requests for medical necessity using InterQual criteria and relevant policies to ensure timely, appropriate care for members.

The position requires an active RN license (NH or compact with NH) and prior authorization experience. Strong communication and decision-making skills are essential, with some travel to the Boston area possible for