Prior Authorization Clinician

Our client is seeking a Prior Authorization Clinician to conduct comprehensive utilization reviews for medical necessity, efficiency, and compliance. This role ensures members receive timely, appropriate care that promotes positive health outcomes while maintaining adherence to clinical and regulatory standards.

This role is fully remote. Occasional travel may be required to Charlestown, Massachusetts.

Prior Authorization Clinician Responsibilities

• Review proposed inpatient, outpatient, and home care services for medical necessity using evidence-based criteria (e.g., InterQual®) and established medical policies.
• Perform pre-certification, concurrent, and retrospective utilization review activities in accordance with internal guidelines and turnaround time requirements.
• Apply sound clinical judgment and critical thinking to determine appropriate levels of care and benefit coverage.
• Communicate and document review outcomes clearly and accurately, ensuring all case activities and correspondence are properly recorded.
• Refer cases to Physician Reviewers when guidelines are not met or additional medical expertise is required, ensuring timely escalation.
• Engage effectively with healthcare providers and internal teams, maintaining professionalism and compliance with established procedures.
• Generate and distribute required notifications and determination letters to providers and members.
• Mentor and provide guidance to other utilization review clinicians, supporting orientation and development of new staff.
• Participate in departmental meetings, training sessions, and process improvement initiatives.
• Maintain compliance with applicable federal, state, and accreditation requirements.
• Identify opportunities to enhance communication, operational workflows, and member service quality.
• Support audit preparation and participate in performance or quality improvement efforts.
• Accurately document rate negotiations to ensure proper claims adjudication.
• Identify and refer cases appropriate for care management intervention.
• Perform additional related duties as required.
  
  

Prior Authorization Clinician Qualifications

• Active, unrestricted Registered Nurse (RN) license in state of residence (compact license accepted).
• Nursing degree or diploma required; Bachelor of Science in Nursing preferred.
• Minimum 2 years of prior authorization or utilization management experience utilizing evidence-based guidelines (such as InterQual).
• Previous experience in managed care or health plan settings strongly preferred.
• Familiarity with Medicare and Medicaid regulations desirable.
• Ability to participate in after-hours on-call rotation, including evenings and weekends.
• Excellent clinical judgment and analytical abilities to assess complex cases.
• Strong verbal and written communication skills with the ability to collaborate effectively across clinical and non-clinical teams.
• High attention to detail with strong organizational and time management capabilities.
• Ability to work independently in a fast-paced, remote environment while adhering to timelines and regulatory requirements.
• Proficiency in Microsoft Office Suite and utilization management or data management systems.
• Commitment to maintaining confidentiality, professionalism, and compliance with all policies and procedures.
• Remote work environment requiring focus and self-discipline.
• Regular attendance and reliability are essential to success in this role.
  
  

Compensation: (DOE)VanderHouwen Contractors Enjoy Exceptional Benefit Perks!

As an eligible contract employee with VanderHouwen, you'll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.

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