Remote Utilization Review RN - AI & Prior Authorization

Pride Health; Minneapolis (MN); Remote; USD 48,000 - 55,000; Full time

Job summary

Pride Health is seeking an experienced Registered Nurse (RN) with Utilization Management experience to support clinical quality review and AI model development for prior authorization use cases. The ideal candidate will review records, apply InterQual/MCG criteria, and lead calibration sessions to ensure consistent application of guidelines and improve annotation accuracy for AI models.

The role requires Minnesota RN licensure, 3+ years in UM or prior authorization, strong CPT/HCPCS and ICD-10

Qualifications

• Bachelor's or Master's degree in Nursing.
• Active, unrestricted RN license in Minnesota.
• Minimum 3 years of experience in clinical quality review, Utilization Management, or prior authorization.
• Health plan or payer-side UM experience with hands-on medical necessity reviews preferred.
• Experience applying evidence-based clinical criteria, such as InterQual and MCG.
• Strong knowledge of CPT/HCPCS, ICD-10 coding, and payer-specific medical necessity guidelines.
• Experience reviewing complex clinical documentation, including progress notes, imaging reports, referrals, and medical orders.
• Strong clinical judgment, analytical thinking, attention to detail, and communication skills.
• Prior experience with clinical annotation, AI/ML projects, quality auditing, or calibration sessions is preferred.
• Shift is 8 hrs/day Mon - Fri, 40 hrs/week
• Fully Remote Position
• Pay Range: $35 - $40 per hour

Responsibilities

• Review, annotate, and audit clinical records and prior authorization cases for accuracy and adherence to clinical guidelines.
• Apply evidence-based criteria, including InterQual and MCG, to evaluate medical necessity and coverage determinations.
• Identify documentation gaps, annotation errors, and inconsistencies in clinical interpretations.
• Provide structured feedback to clinical reviewers and annotators to improve quality and consistency.
• Lead calibration sessions to align clinical interpretations and annotation standards.
• Monitor quality metrics, including inter-rater reliability (IRR), agreement rates, precision, recall, and F1 scores.
• Collaborate with clinical quality teams and AI/ML teams to improve annotation accuracy and model performance.
• Maintain quality audit documentation, scoring rubrics, and clinical annotation guidelines.
• Support training, mentoring, and continuous improvement initiatives for clinical annotators.

Skills

Clinical quality review

Utilization Management

Prior authorization

InterQual

MCG

CPT/HCPCS coding

ICD-10 coding

Analytical thinking

Communication

Calibration leadership

Training/mentoring

Education

Bachelor's or Master's degree in Nursing

RN license Minnesota (active, unrestricted)

Job description

Pride Health is seeking an experienced Registered Nurse (RN) with Utilization Management experience to support clinical quality review and AI model development for prior authorization use cases. The ideal candidate will review records, apply InterQual/MCG criteria, and lead calibration sessions to ensure consistent application of guidelines and improve annotation accuracy for AI models.

The role requires Minnesota RN licensure, 3+ years in UM or prior authorization, strong CPT/HCPCS and ICD-10