Prior Authorization Clinician in Boston, Massachusetts - #71936 | VanderHouwen

Description

Job Id: 71936

Prior Authorization Clinician (RN)
Our client is seeking a detail-oriented and clinically strong Prior Authorization Clinician to support utilization review activities and ensure members receive appropriate, timely, and evidence-based care. This role requires sound clinical judgment, the ability to navigate complex cases, and a commitment to regulatory compliance and quality outcomes in a fast-paced, remote environment.

This role is fully remote. Applicants may be required to occasionally travel to Boston, Massachusetts for meetings.

Prior Authorization Clinician Responsibilities

• Evaluate inpatient, outpatient, and home care service requests for medical necessity using established clinical guidelines and benefit criteria.
• Conduct utilization reviews including pre-certification, concurrent, and retrospective assessments in accordance with regulatory and organizational standards.
• Apply evidence-based criteria to determine appropriate levels of care and coverage decisions.
• Accurately document all review activities, determinations, and communications within required systems and timelines.
• Escalate cases that do not meet medical necessity criteria to physician reviewers, ensuring timely handoff for further evaluation.
• Communicate determinations effectively with providers, members, and internal stakeholders, including issuance of required notifications.
• Ensure adherence to federal, state, and accreditation standards, including mandated turnaround times.
• Identify and refer members who may benefit from care management or additional support services.
• Contribute to process improvements, audits, and team initiatives to enhance quality and efficiency.
• Support team collaboration through participation in meetings, training, and mentorship of newer staff as needed.

Prior Authorization Clinician Qualifications

• Active, unrestricted Registered Nurse (RN) license in state of residence (compact license preferred where applicable).
• Minimum of 2+ years of prior authorization or utilization review experience within a managed care environment.
• Demonstrated experience applying evidence-based clinical guidelines (e.g., InterQual or similar criteria).
• Strong clinical judgment and critical thinking skills with the ability to assess complex cases independently.
• Solid understanding of Medicare, Medicaid, and/or commercial health plan structures and requirements.
• Excellent written and verbal communication skills with the ability to collaborate across multidisciplinary teams.
• Proven ability to manage workload independently in a remote setting while meeting strict deadlines and turnaround times.
• Proficiency with Microsoft Office and electronic documentation or case management systems.
• Strong organizational skills with attention to detail and accuracy in documentation.

Compensation: (DOE)

VanderHouwen Contractors Enjoy Exceptional Benefit Perks!
As an eligible contract employee with VanderHouwen, you’ll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.

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VanderHouwen is an award-winning, Women & Diversity-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen places experienced professionals across the nation! Our recruitment teams specialize in either Technology and IT, Engineering, Human Resources, or Accounting and Finance career markets. Partner with us to land your next exciting career!

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