Prior Authorization UM Nurse Consultant - Louisiana Preferred
Core
Review prior authorization requests across medical specialties to evaluate medical necessity and support authorization determinations using evidence-based clinical review.
Role type
Utilization Management Nurse Consultant (RN)
Builds
Timely, appropriate, and cost-effective healthcare service authorizations for health plan members.
Domain
Health insurance / Utilization Management
Required skills
Clinical nursing assessment, critical thinking, decision-making, medical record review, knowledge of InterQual/MCG criteria, regulatory compliance, multi-priority management, electronic medical records proficiency
Preferred skills
BSN, Medicaid/Medicare/Commercial plan experience, inpatient/outpatient/surgical review, state/federal UM regulations knowledge, remote work experience, Louisiana residency, Louisiana Medicaid population support
Technologies
InterQual, MCG, Electronic Medical Records (EMR), Microsoft Office 365, Teams, Outlook, VPN, EHR portals
Responsibilities
Review prior authorization requests, evaluate medical necessity using clinical records and guidelines, apply InterQual/MCG criteria, collaborate with providers and care managers, ensure compliance with health plan policies and regulations, manage high-volume caseload
Seniority
Mid-level, hands-on IC