Prior Authorization RN

Location: NEWARK, NJ, USA Salary: $35.00 USD Hourly - $39.00 USD Hourly Description 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.

Key Responsibilities

• 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.

Qualifications

• Active NJ or Compact RN license
• Reside in NJ, PA, NY, MD, or CT
• Minimum of 3 years of clinical RN experience
• At least 2 years working in a Health Plan within Prior Authorization or Utilization Review
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint) and other Windows-based software
• Strong understanding of hospital structures and payment systems
• Knowledge of case, care, and disease management principles and operations

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