Job Overview – Utilization Review Nurse (Prior Authorization)
Compensation: $47/hour
Location: Boston, MA (Remote)
Atlantic Group is hiring a Utilization Review Nurse (Prior Authorization) in Boston, MA for our client, supporting utilization review, prior authorization, and medical necessity determinations within a managed care environment. This role focuses on reviewing inpatient and outpatient service requests, applying evidence-based guidelines, and ensuring timely, compliant care decisions. The Prior Authorization Nurse will utilize InterQual criteria, EMR systems, and clinical judgment to support patient outcomes and regulatory compliance.
Responsibilities as the Utilization Review Nurse (Prior Authorization):
- Utilization Review: Perform pre-certification, concurrent, and retrospective reviews to determine medical necessity.
- Medical Necessity Evaluation: Apply clinical guidelines and policies to assess appropriateness of care.
- Care Coordination: Communicate with providers and internal teams to support timely authorization decisions.
- Documentation: Maintain accurate and timely records of all review activities and decisions.
- Escalation Management: Refer complex or non-qualifying cases to physician reviewers as needed.
Qualifications for the Utilization Review Nurse (Prior Authorization):
- Education: Associate’s or Bachelor’s degree in Nursing from an accredited program is required.
- Licensure: Active, unrestricted Registered Nurse (RN) license in the state of residence or compact license is required.
- Experience: 2+ years of prior authorization or utilization review experience within a managed care environment is required.
- Industry Knowledge: Familiarity with Medicare, Medicaid, and evidence-based guidelines such as InterQual is preferred.
- Technical Skills: Proficiency in EMR systems, Microsoft Office, and clinical data management tools is required.
- Skills & Attributes: Demonstrates strong clinical judgment, critical thinking, communication skills, and the ability to work independently in a remote setting.
Application Notice: Qualified candidates will be contacted within 2 business days of application. If an applicant does not meet the above criteria, Atlantic Group will keep your resume on file for future opportunities and may contact you for further discussion.