Prior Authorization Clinician - Home Care

Prior Authorization Clinician - Home Care

Our client, a nonprofit managed care organization affiliated with a major academic healthcare system, is seeking a Prior Authorization Clinician to join its utilization management team for a 3-month contract with the potential to extend. This person will be responsible for reviewing home care and home health service requests for medical necessity, appropriate utilization, and benefit coverage.

The ideal candidate will have experience on both sides of home care: direct clinical experience providing care to patients in their homes and payer-side prior authorization experience reviewing home care requests for an insurance company or managed care organization.

Key Responsibilities

• Review prior authorization requests for home care and home health services to determine medical necessity, appropriate level of care, and benefit coverage.

• Evaluate submitted clinical documentation and apply evidence-based guidelines, including InterQual criteria, medical policies, and benefit requirements.

• Complete first-level clinical reviews and approve services that meet established medical-necessity criteria.

• Refer cases that do not meet criteria or lack applicable guidelines to a Physician Reviewer in accordance with departmental workflows.

• Perform pre-certification, concurrent, and retrospective utilization reviews as assigned.

• Document all review activities, clinical findings, communications, and determinations accurately within applicable systems.

• Communicate professionally with providers, clinical staff, internal stakeholders, and physician reviewers regarding authorization requests.

• Ensure cases are completed within applicable Medicaid, Medicare, ACA, CMS, NCQA, and departmental turnaround times.

• Maintain established productivity expectations while consistently meeting quality and audit standards.

• Generate and send appropriate determination letters to providers and members.

• Identify potential cases for referral to Care Management.

• Support and coach other utilization review nurses and assist with the orientation of newly hired team members as needed.

• Participate in team meetings, educational activities, quality initiatives, and audit-related activities.

• Identify opportunities to improve utilization review workflows, documentation, and communication.

• Maintain compliance with all departmental policies and applicable federal, state, and accreditation requirements.

Qualifications

• Nursing degree or diploma required; bachelor’s degree in nursing preferred.

• Active, unrestricted RN license in the state of residence required.

• Appropriate Massachusetts, New Hampshire, or compact-state licensure required.

• Direct outpatient home care or visiting nurse experience providing clinical care to patients in their homes required.

• At least 2 years of payer-side prior authorization or utilization review experience required.

• Payer-side experience reviewing home care or home health authorization requests required.

• Experience applying InterQual or comparable evidence-based criteria to clinical documentation required.

• Managed care or health insurance experience required.

• Experience working under defined productivity expectations while maintaining quality, accuracy, and regulatory turnaround times required.

• Medicare and Medicaid knowledge preferred.

• Strong clinical judgment and critical-thinking skills.

• Excellent written and verbal communication skills.

• Strong organizational and time-management skills with the ability to manage a high-volume caseload independently.

• Proficiency with Microsoft Office applications and utilization management or clinical data systems.

• Ability to take after-hours calls, including evenings, nights, or weekends, as required.

• Ability to comply with all organizational remote-work requirements.

Work Arrangement: Fully remote, with possible travel to Charlestown, Massachusetts for training or team meetings.

Pay Rate: $50.00–$53.00 per hour

If you are interested in this position, please send your resume to apowell@daleyaa.com.

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