Prior Authorization RN

Job Title: Prior Authorization Registered Nurse (RN) Location: Remote (Candidates must reside in NJ, PA, NY, MD, or CT) Schedule: Monday-Friday, 8:00 AM - 5:00 PM EST Caseload: 10-35 cases per day, depending on demand Job Overview: This role is responsible for ensuring patients receive appropriate, high-quality, and cost-effective care throughout their healthcare journey. The RN will assess medical appropriateness, coordinate patient care, advocate for members, and ensure compliance with established guidelines.

Prior Authorization & Medical Appropriateness: Evaluate clinical needs against guidelines to determine the medical necessity of inpatient stays, services, and procedures. Care Coordination & Planning: Develop and implement patient care plans, facilitating seamless care transitions and service delivery. Quality & Cost-Effectiveness: Monitor and optimize care to ensure adherence to clinical guidelines and positive patient outcomes. Participate in quality improvement initiatives. Patient Advocacy: Support members and families, coordinate resource utilization, and assess services across various healthcare settings. Program Referrals & Compliance: Encourage member participation in case and disease management programs through appropriate referrals. Documentation & Communication: Maintain accurate documentation and facilitate efficient communication with multidisciplinary teams through telephonic and in-person interactions. Fiscal Accountability: Ensure responsible resource utilization while supporting self-care outcomes and maintaining financial responsibility.