Utilization Management Specialist (Home-Based) - Prior Authorization

Responsibilities: Conduct medical necessity and level of care reviews using InterQual criteria to ensure appropriate resource utilization and cost control. Coordinate prior authorization processes and collaborate with healthcare professionals to improve documentation and compliance with regulatory standards.

Requirements: Requires a degree from a nationally accredited nursing program and a current, unencumbered Registered Nurse (RN) license. A Bachelor's degree in nursing is preferred, along with knowledge of oncology.

Key skills: Utilization Management, Prior Authorization, Medical Necessity Review, InterQual Criteria, Patient Chart Review, DRG Coding, Oncology Knowledge, Clinical Documentation Improvement, Regulatory Compliance, Case Escalation, Insurance Denial Management, Resource Utilization

Keywords: Utilization Management, Prior Authorization, InterQual, Medical Necessity, Registered Nurse, RN License, DRG, CMS, NCD/LCD, Oncology, Patient Chart Review, Healthcare Compliance, Case Management, Clinical Decision Support, Rural Health