Prior Authorization Clinician in Boston, Massachusetts - #73056 | VanderHouwen

Description

Job Id: 73056

Prior Authorization Clinician
Our client is seeking a clinically experienced Prior Authorization Clinician with a strong background in both direct outpatient home care and payer-side prior authorization review. This individual will bring sound clinical judgment, strong attention to detail, and the ability to efficiently evaluate clinical documentation against established medical necessity criteria. The ideal candidate is comfortable working in a high-volume environment with defined productivity expectations while consistently maintaining accuracy, quality, and regulatory compliance.

This position is fully remote, with occasional travel to Boston, Massachusetts for team meetings or training as needed.

Prior Authorization Clinician Responsibilities

• Review outpatient home care authorization requests on the payer side, evaluating clinical documentation against established medical necessity criteria and benefit requirements.
• Apply evidence-based guidelines, including InterQual or similar criteria, to determine whether requested services meet requirements for authorization and appropriate utilization.
• Perform utilization management reviews, document determinations thoroughly, and escalate cases requiring additional clinical review to the appropriate physician reviewer.
• Manage authorization cases within established productivity, quality, regulatory, and turnaround-time requirements while maintaining accurate and timely documentation.
• Communicate review outcomes and case information with providers and internal stakeholders, identify appropriate referrals to care management, and support continuous improvement of utilization review processes.
• Maintain compliance with applicable federal, state, accreditation, and organizational requirements while following established workflows and policies.
• Provide guidance to other utilization review clinicians as needed and participate in team meetings, training, audits, and departmental initiatives.

Prior Authorization Clinician Qualifications

• Active, unrestricted RN license in the candidate’s state of residence; Massachusetts, New Hampshire, or compact-state licensure is preferred.
• Direct patient-care experience in an outpatient home care setting, such as home health or visiting nursing, is required.
• 2+ years of payer-side prior authorization or utilization review experience, specifically evaluating home care services for medical necessity and coverage, is required.
• Experience applying evidence-based clinical criteria, such as InterQual, to authorization decisions and interpreting clinical documentation against coverage requirements.
• Demonstrated ability to meet established productivity and turnaround-time expectations while maintaining high standards for review quality and accuracy.
• Managed care experience and familiarity with Medicare, Medicaid, and applicable utilization management requirements are strongly preferred.
• Nursing degree or diploma is required; a bachelor’s degree in nursing is preferred.
• Strong clinical judgment, critical-thinking, communication, organizational, and time-management skills, with the ability to work independently in a fast-paced remote environment.
• Proficiency with Microsoft Office and clinical or utilization management systems, with flexibility to support after-hours coverage as needed.

Compensation: (DOE)

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