Prior Authorization Clinician (Remote) in Boston, Massachusetts - #73057 | VanderHouwen

Description

Job Id: 73057

Prior Authorization Clinician (Remote)
Our client is seeking a clinically experienced Prior Authorization Clinician who combines hands-on home care knowledge with strong payer-side utilization review expertise. The ideal candidate brings sound clinical judgment, critical thinking, and attention to detail while working efficiently in a high-volume environment and maintaining consistent quality and regulatory standards.

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 for medical necessity by applying established clinical criteria and evidence-based guidelines to supporting documentation.
• Perform payer-side prior authorization and utilization review activities, making timely and well-supported coverage determinations within required turnaround times.
• Evaluate complex clinical information, document review decisions accurately, and escalate cases requiring physician review when established criteria are not met.
• Communicate effectively with providers, clinical teams, and internal stakeholders while maintaining complete and compliant case documentation.
• Meet established productivity and quality expectations while supporting regulatory compliance, process improvement, and appropriate referrals to care management.

Prior Authorization Clinician Qualifications

• Active, unrestricted RN license in the state of residence, with a nursing degree or diploma required; bachelor’s degree in nursing preferred.
• Direct outpatient home care experience providing patient care and payer-side prior authorization experience reviewing home care services are both required.
• 2+ years of prior authorization/utilization review experience using evidence-based clinical criteria, such as InterQual, within a managed care or health insurance environment.
• Strong clinical judgment, analytical thinking, organization, and communication skills with demonstrated success balancing review quality and productivity expectations.
• Ability to work independently in a fast-paced remote environment, meet regulatory timelines, and participate in after-hours coverage as needed; Medicare and Medicaid knowledge is preferred.

Compensation: $45-$50/hr. (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.

Meet VanderHouwen
What kind of recruiter do you see yourself working with? One who prioritizes your best interest, no matter what? VanderHouwen does, and we’re in it for the long game! Our recruiters focus on YOU, building meaningful, long-term relationships while developing a deep understanding of companies’ staffing needs and workplace cultures. This approach helps us find an ideal job match that aligns with your unique career aspirations and goals.

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!

VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.

#LI-Remote