Prior Authorization Clinician (RN)
Salary: $90,000 – $110,000 + Benefits
Location: Fully Remote*
(*We are unable to hire in: AK, AR, CA, DE, HI, IA, LA, MS, MT, NE, ND, SD, DC, WY)

About the Role
We are seeking an experienced Prior Authorization Clinician (RN) to review proposed hospitalizations, home care, and inpatient/outpatient services for medical necessity, ensuring timely and appropriate care for our members. This fully remote role is fast-paced and metrics-driven, requiring strong clinical judgment, attention to detail, and the ability to work independently.

Must-Haves

• Active RN license in MA, NH, or a compact-eligible state

• 2+ years direct prior authorization (pre-cert/pre-auth) experience within an insurance or managed care environment

• Experience with InterQual (or other evidence-based decision guidelines)

• Ability to thrive in a fast-paced, metric-driven remote environment

Nice-to-Haves

• Medicaid experience, especially with Massachusetts or New Hampshire programs

• Medicare experience

• Previous remote work experience

Key Responsibilities

• Review inpatient and outpatient services for medical appropriateness using InterQual, Medical Policy, and benefit determinations

• Conduct utilization reviews (pre-cert, concurrent, retrospective) and document outcomes

• Refer cases to Physician Reviewer when necessary and ensure timely provider communication

• Collaborate with providers, internal teams, and members to support optimal health outcomes

• Maintain compliance with Federal, State, and accreditation requirements

• Participate in team meetings, audits, and process improvement initiatives

Qualifications

• Nursing degree or diploma required; BSN preferred

• Active, unrestricted RN license (MA, NH, or compact)

• 2+ years prior authorization experience with evidence-based guidelines

• Managed care experience

• Strong communication, critical thinking, and organizational skills

• Proficiency in Microsoft Office and documentation systems

Working Conditions

• Fully remote with occasional travel to Charlestown, MA for team meetings/training

• Desk-based role requiring focus and adaptability

If you are a detail-oriented RN with prior authorization expertise and a passion for delivering high-quality, efficient care, we’d love to hear from you!