RN Medical Management
Core
Review prior authorization cases using clinical guidelines to support quality outcomes and cost-effective care.
Role type
Senior IC medical management nurse (prior authorization)
Builds
Pre-service determinations, concurrent reviews, and case management functions for health plan consumers and providers
Domain
Healthcare / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Registered Nurse licensure, prior authorization experience, utilization management experience, CareWebQI/InterQual proficiency, clinical background, remote work adaptability
Preferred skills
Certified Case Manager (CCM), MCG Certification, RN-BC Registered Nurse Case Manager, Certification in Managed Care Nursing (CMCN)
Technologies
Microsoft Outlook, Teams, Word, CareWebQI, InterQual
Responsibilities
Process health plan medical pre-service requests, evaluate medical necessity and appropriateness of care, collaborate with providers on prior authorization issues, document interventions in medical records, provide ongoing education to stakeholders, conduct call rotations for health plan and department
Seniority
Senior, hands-on IC