NH Licensed Prior Authorization Nurse

To ensure members receive appropriate and timely care, the full-time remote NH Licensed Prior Authorization Nurse will review hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency, utilizing evidence-based guidelines. Key responsibilities: Determines medical appropriateness of services using InterQual criteria and medical policies Performs utilization reviews, including pre-certification and concurrent reviews, according to established guidelines Communicates outcomes of utilization reviews and refers cases to Physician Reviewers when necessary Required qualifications: Nursing degree or diploma required Active RN License in the state of NH or a compact eligible state that includes NH 2+ years of prior authorization experience with evidence-based guidelines Managed care experience preferred Knowledge of Medicare and Medicaid is desirable