Remote Prior Authorization RN – NJ, PA, NY, CT, MD, Compact

Currently seeking a Prior Authorization RN – Remote.

Location Requirement: Candidate must reside in NJ, PA, NY, CT, or MD

Work Model: WFH, but must be able to pick up and return equipment in person

Schedule: Monday–Friday, 8:00 AM–5:00 PM

Contract Length: 3 months (extensions possible)

Training: 2 weeks (may include mentor support and early case handling)

Case Volume: 10–35 cases/day depending on business need

Role Overview

The Prior Authorization RN is responsible for reviewing medical authorization requests to ensure medical necessity, appropriate level of care, and compliance with clinical guidelines. This role supports utilization management, provider communication, and care coordination to promote high‑quality, cost‑effective care.

Responsibilities

• Review prior authorization requests for medical necessity, appropriateness, and compliance with clinical guidelines, policies, and regulatory requirements.
• Assess appropriate level of care, treatment, services, and length of stay to support authorization decisions.
• Evaluate clinical documentation and collaborate with providers to obtain additional information when needed.
• Process authorization requests accurately and within required turnaround times.
• Coordinate with physicians, facilities, vendors, and internal teams to ensure timely determinations and continuity of care.
• Monitor and coordinate out‑of‑network and out‑of‑area services per plan policies and benefit guidelines.
• Educate providers and members on authorization requirements, coverage criteria, and available resources.
• Identify cases requiring physician review and escalate appropriately.
• Document all reviews, determinations, and communications thoroughly in designated systems.
• Support quality and cost‑effective care through consistent application of evidence‑based criteria and utilization management principles.

Qualifications

• Active NJ RN license or Compact RN license
• 2+ years of prior authorization experience within a health plan
• Strong computer proficiency
• Must reside in NJ, PA, NY, CT, or MD
• Must be able to pick up/drop off equipment in person at Pennington, NJ