Healthcare Consultant III – RN {166856}
Outpatient Prior Authorization (Remote)
Pay Rate: $37.16/hour
Target Start Date: April 13
Schedule: Monday–Friday, 8:00 AM–5:00 PM (aligned to Arizona time zone)
Work Arrangement: Fully remote
Position Summary
The RN – Outpatient Prior Authorization is responsible for reviewing outpatient service requests and applying medical necessity criteria, evidence-based guidelines, and organizational policies to support accurate and timely determinations.
This role is dedicated exclusively to outpatient prior authorization and plays a key role in ensuring high-quality, compliant review processes. The position will also support the transition from QNXT to MedCompass, including workflow validation, testing, and process stabilization during implementation.
Key Responsibilities
• Review outpatient prior authorization requests using appropriate medical necessity criteria (local/state guidelines, Medicare NCD/LCD, MCG where applicable)
• Gather and interpret clinical documentation to support review determinations
• Document accurate and audit-ready review outcomes
• Ensure timely and compliant determinations aligned with state and federal requirements
• Communicate determination outcomes professionally to providers and internal partners
• Participate in MedCompass implementation activities, including user testing, workflow validation, defect identification, and process refinement
• Maintain high accuracy, reliability, and quality standards in clinical decision-making
• Adapt to workflow changes during system transition and stabilization
Required Qualifications
• Active, unrestricted Compact RN license
• Associate’s Degree in Nursing
• Minimum 3 years of recent clinical RN experience in acute care, ED, ICU, Telemetry, Med/Surg, or Home Health
• Ability to apply medical necessity criteria and demonstrate strong criteria-based clinical decision-making skills
• Ability to work a full 40-hour workweek aligned with Arizona time zone
• Collaborative, team-oriented approach with a professional attitude
• Ability to manage high-volume, repetitive work while maintaining focus and accuracy
• Willingness to work occasional weekends, if needed
Preferred Qualifications
• Prior authorization or utilization management experience
• Experience with MCG, InterQual, Medicare NCD/LCD, or similar guidelines
• Experience with QNXT, MedCompass, or similar systems
• Experience supporting system transitions or healthcare technology implementations
• Bachelor of Science in Nursing (BSN)
Competency Expectations
• High level of accuracy and quality in clinical review and documentation
• Strong proficiency in applying medical necessity criteria (NCD/LCD, Medicaid policy, MCG)
• Adaptability during system changes and workflow stabilization
• Strong focus, consistency, and reliability in a high-volume review environment