Prior Authorization RN

Location: Philadelphia, PA Salary: $40.00 USD Hourly - $43.50 USD Hourly Description: The Judge Group is currently seeking a full time Remote Prior Authorization RN for a fantastic client of ours located in Philadelphia, PA! This is a great opportunity to get your foot in the door with one of the nations largest leading healthcare company's! Below is a basic overview of the opportunity! Interested and qualified RNs are encouraged to apply! Job Summary The Registered Nurse (RN) is responsible for conducting comprehensive clinical evaluations through the review of medical records—including medical history, treatment documentation, and proposed care plans—to determine the medical necessity of services. This role requires advanced clinical knowledge, independent judgment, and the application of established medical necessity criteria. The RN interacts directly with healthcare providers when additional clinical information is required and possesses the authority to independently authorize medically necessary services on behalf of the organization. Cases that do not meet established criteria are escalated with supporting documentation to the Medical Director for further evaluation. Key ResponsibilitiesClinical Review & Medical Necessity Determination • Apply advanced clinical knowledge, critical thinking, and sound judgment to evaluate medical records and make case determinations using approved guidelines and resources. • Utilize InterQual criteria, Care Management Policy, Medical Policy, and electronic reference tools to assess the appropriateness of proposed treatment plans. • Determine medical necessity for inpatient admissions, continued stay, length of stay, procedures, and ancillary services in accordance with InterQual and Medical Policy standards. Provider Communication & Care Coordination • Communicate directly with servicing providers to clarify treatment plans, obtain necessary clinical documentation, and validate the medical need for requested services. • Review and discuss treatment plans, inpatient admission requests, and continued stay requirements with providers, ensuring all criteria-based questions are addressed. • Identify cases requiring escalation and refer to the Medical Director when treatment plans do not meet established criteria. Discharge Planning & Care Management Collaboration • Identify members early who may require discharge planning support. • Collaborate with case management staff and physicians to evaluate alternative care settings and facilitate discharge to the most appropriate level of care. • Refer cases appropriately to Quality Management, Care Management and Coordination, Case Management, or Disease Management based on identified needs. Regulatory Compliance & Documentation • Verify that all requested services fall within the member’s benefit plan coverage. • Ensure that utilization management decisions comply with applicable state, federal, and accreditation standards. • Meet or exceed regulatory turnaround requirements and departmental productivity goals related to referral and authorization processing. • Document all essential functions in alignment with Care Management and Coordination policies. • Maintain accurate, timely entries to ensure data integrity within internal systems. Operational Excellence • Identify and report potential utilization trends or issues to management and recommend opportunities for improvement. • Support continuous improvement efforts within the Care Management and Coordination department. Again, interested and qualified candidates are encouraged to apply. I will get back to you right away on your application! For other questions, please feel free to email me directly at [email protected] Thank You, Jacob By providing your phone number, you consent to: (1) receive automated text messages and calls from the Judge Group, Inc. and its affiliates (collectively "Judge") to such phone number regarding job opportunities, your job application, and for other related purposes. Message & data rates apply and message frequency may vary. Consistent with Judge's Privacy Policy, information obtained from your consent will not be shared with third parties for marketing/promotional purposes. Reply STOP to opt out of receiving telephone calls and text messages from Judge and HELP for help. Contact: [email protected] This job and many more are available through The Judge Group. Find us on the web at www.judge.com Remote About the Company: Judge Group The Judge Group Inc., is a leading professional services firm specializing in talent, technology, and learning solutions. We consult, staff, train, and solve. Through our work we make people and organizations better. Our services are successfully delivered through a network of more than 30 offices across the United States, Canada, and India. The Judge Group 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 (including aerospace and defense), manufacturing, and technology and telecommunications. If you would like to learn more about The Judge Group visit www.judge.com or call toll free (800) 360-4474. Company Size: 5,000 to 9,999 employees Industry: Computer/IT Services Founded: 1970 Website: https://www.judge.com