Healthcare Consultant III

Job Summary:

• The RN – Outpatient Prior Authorization performs clinical review of outpatient service requests using medical necessity criteria, evidence based guidelines, and organizational policy.
• This role is dedicated to outpatient prior authorization only and supports high quality, accurate, and timely determinations.
• The position will play a key role in the transition from QNXT to Med Compass, including workflow validation, testing, and stabilization of new processes during implementation.

Duties & Responsibilities:

• Review outpatient prior authorization requests and apply appropriate medical necessity criteria (local/state guidelines, Medicare NCD/LCD, MCG where applicable).
• Gather and interpret clinical information and document accurate review outcomes.
• Ensure compliant, timely determinations aligned with state/federal requirements.
• Participate in MedCompass implementation activities: user testing, workflow validation, defect identification, and process refinement.
• Communicate determination outcomes professionally to providers and internal partners.
• Maintain high accuracy, reliability, and auditready documentation standards.

Education and License:

• Associates Degree in Nursing.
• Active Compact RN License.
• BSN preferred.

Experience:

• Minimum 3 years clinical experience (acute care, ED, ICU, Telemetry, Med/Surg, Home Health, etc.).
• Prior authorization or utilization management experience.
• Experience with MCG, InterQual, QNXT, or similar systems.
• Experience in system transitions or healthcare technology implementations.

Skills & Competencies:

• High accuracy and quality in clinical decision making and documentation.
• Proficiency with criteria application (NCD/LCD, Medicaid policy, MCG).
• Adaptability during system change and workflow stabilization.
• A strong clinical foundation is needed to make accurate PA determinations.
• Prior Authorization or Utilization Review experience OR strong criteriabased clinical decisionmaking skills.
• Collaborative, teamoriented approach with a positive, professional attitude.
• Comfort with highvolume, repetitive work and the ability to remain focused while performing similar tasks daily.
• Willingness to work occasional weekends, if needed.