Pre Certification RN

National Healthcare Recruiting Manager @ The Judge Group | Connecting top healthcare workers with their dream jobPre-Certification RNLocation: Remote (must reside in PA, NJ, or DE)Employment Type: Temporary with potential for permanent placementSchedule: Monday–Friday, Day ShiftPay: Up to $45/hourSummaryThe Pre-Certification RN evaluates members’ clinical conditions through medical record review to determine medical necessity for services. This role applies advanced clinical judgment, interacts with providers for additional information when needed, and authorizes medically necessary services. Cases not meeting criteria are referred to the Medical Director for further evaluation. The RN ensures compliance with federal, state, and accreditation regulations and acts as a patient advocate throughout the care process.Key ResponsibilitiesReview medical records to determine medical necessity using InterQual and medical policy criteria.Authorize services that meet established criteria; refer non-qualifying cases to the Medical Director.Communicate with providers to clarify treatment plans and medical needs.Ensure requests align with member benefit plans and regulatory requirements.Identify discharge planning needs and collaborate with case management staff.Maintain accurate documentation and meet turnaround time and productivity goals.Report utilization trends and quality-of-care issues as needed.QualificationsActive RN license in PA or Compact license including PA.Minimum 3 years of acute care clinical RN experience in a hospital or healthcare setting.Prior discharge planning or utilization management experience preferred. #J-18808-Ljbffr