Precertification RN

The Judge Group is an international leader in business technology consulting, talent solutions, and learning and development. With over 30 locations across the U.S., Canada & India, Judge is proud to partner with the best and brightest companies in business today, including over 60 of the Fortune 100. We serve organizations in financial services, healthcare, life sciences, insurance, government, aerospace & defense, manufacturing, and technology & telecommunications. Judge has always been committed to doing what’s right – for our colleagues, our client partners, and our communities. At Judge, we cultivate an inclusive environment that empowers our employees to produce their best work. As a family-owned business, we’re not just a high-performing team, but a high-performing family. Through building relationships and our cultural commitment to caring, we support one another.

Our client is currently seeking a Precertification RN: Precertification RN – PT/OT/ST & Bariatric Reviews Location: Remote (Must reside in PA, NJ, or DE) License Required: Active PA RN or LPN (Compact licenses not accepted) REQUIRED Contract Duration: Ongoing (3+ months) Join our dynamic Precertification team, where your clinical expertise will help ensure members receive medically necessary care in a timely and compliant manner. As a Precertification RN, you will conduct thorough reviews of medical records—including history and treatment plans—to determine the appropriateness of services such as physical therapy (PT), occupational therapy (OT), speech therapy (ST), and bariatric procedures. You’ll apply clinical criteria, collaborate with providers, and advocate for members navigating the healthcare system.

Clinical Review & Determination: Evaluate healthcare service requests using advanced clinical knowledge and independent judgment Apply established guidelines (e.g., InterQual, Medical Policy) to assess medical necessity for inpatient admissions, procedures, and ancillary services Collaborate with providers to clarify clinical details and ensure alignment with criteria Refer cases to the Medical Director when services fall outside standard guidelines Care Coordination & Referral: Identify members early for discharge planning and coordinate appropriate transitions Refer cases to Case Management, Disease Management, or Quality Management as needed Compliance & Documentation: Confirm service coverage under member health plans Ensure all decisions meet federal, state, and accreditation standards Meet regulatory turnaround times and productivity goals Maintain accurate documentation and data integrity Utilization Management Monitor and report utilization trends Recommend process improvements to enhance efficiency and care quality