Job Description
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
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