Utilization Review Nurse/ Registered Nurse (100% REMOTE)

Position Summary

Responsible for clinical criteria prior authorization setup to meet client needs and ensure operational efficiency. No direct patient care.

Key Responsibilities

• Responsible for clinical criteria prior authorization setup, creating prior authorization requests sent to prescribers based on client clinical policy requirements.
• Create questions, answers, and additional configurations allowing prescribers to answer questions leading to approval or denial.
• Create and code denial rationales sent to prescribers and patients using a web-based proprietary platform.
• Provide configuration support for both pharmacy and medical criteria using problem-solving skills.
• Offer consultative support in explaining setup and system requirements to internal business partners and clients.