[Hiring] Prior Authorization Medical Clinician @WellSense Health Plan

Role Description

The Prior Authorization Clinician is responsible for reviewing all proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency to ensure members receive the appropriate and timely care to support members in achieving optimal health outcomes.

• Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines applying evidenced-based InterQual® criteria, Medical Policy and benefit determination.
• Performs utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines.
• Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria.
• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication.
• Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available.
• Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures.
• Sends appropriate system-generated letters to provider and member.
• Provides guidance and coaching to other utilization review nurses and participates in the orientation of newly hired utilization nurses.
• Follows all departmental policies and workflows in end-to-end management of cases.
• Participates in team meetings, education, discussions, and related activities.
• Maintains compliance with Federal, State and accreditation organizations.
• Identifies opportunities for improved communication or processes.
• May participate in audit activities and meetings.
• Documents rate negotiation accurately for proper claims adjudication.
• Identifies and refers potential cases to Care Management.
• Performs all other related duties as assigned.

Qualifications

• Nursing degree or diploma required.
• Preferred/Desirable: Bachelor's degree.
• Medicare and Medicaid knowledge.
• 2+ years prior authorization experience and evidence-based guidelines (InterQual Guidelines).
• Managed care experience.

Requirements

• Active RN License in the state of NH, or a compact eligible state that includes NH.
• Pre-employment background check.
• Ability to take after hours call, including evening/nights/weekends.

Benefits

• Full-time remote work.
• Competitive salaries.
• Excellent benefits.
• Generous total compensation that includes benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Working Conditions and Physical Effort

• Fully remote position with possible travel to the Charlestown, MA office for team meetings and training sessions.
• Fast paced and dynamic work environment requiring adaptability and focus.
• Minimal physical effort required; primarily desk-based tasks such as documentation and virtual meetings.
• Regular and reliable attendance is essential.

Compensation Range

$35.58 - $51.44. This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer.