Prior Authorization UM Nurse Consultant
Core
Review prior authorization requests and medical records to determine medical necessity for members across broad medical specialties.
Role type
Utilization Management Nurse Consultant (RN)
Builds
Timely and accurate utilization management decisions supporting effective resource utilization.
Domain
Health insurance / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical assessment, critical thinking, decision-making, evidence-based criteria application, regulatory compliance knowledge, electronic medical records proficiency, multi-priority management
Preferred skills
Medicaid/Medicare/Commercial plan support, inpatient/outpatient/surgical/diagnostic/specialty/ancillary service review, state/federal UM regulations knowledge, remote work experience, Louisiana residency
Technologies
InterQual, MCG, electronic medical records, utilization management platforms, Microsoft Office 365, Teams, Outlook, Word, Excel, PowerPoint, VPN, EHR portal
Responsibilities
Review prior authorization requests and medical records to determine medical necessity; Apply evidence-based clinical guidelines, benefit plans, and regulatory requirements to authorization decisions; Utilize InterQual, MCG, or similar clinical criteria to support consistent, quality outcomes; Collaborate with providers, care managers, medical directors, and interdisciplinary teams; Manage a high-volume caseload in a fast-paced, deadline-driven environment; Ensure members receive clinically appropriate care while supporting effective resource utilization
Seniority
Mid-level, hands-on IC