Precertification Nurse RN

Precertification Nurse RN

Location: Springfield, NJ (Onsite for first 90 days, then Hybrid)
Schedule: Monday-Friday, 9:00 AM-5:00 PM or 8:30 AM-4:30 PM
Salary: $65,000-$70,000 (Negotiable)

About the Opportunity

Join a well-established employee benefits organization that provides healthcare and insurance support services to its membership population. This position is ideal for a Registered Nurse seeking a non-bedside role focused on clinical review, healthcare coordination, and member support.

The role combines precertification, utilization review, and care coordination responsibilities while helping members understand and access their healthcare benefits. This is primarily an office-based position with a stable weekday schedule and excellent work-life balance.

Key Responsibilities

Precertification & Clinical Review (Approximately 70%)

• Review requests for medical services, procedures, and treatments to determine benefit eligibility and coverage.
• Collect and evaluate clinical information from healthcare providers and members.
• Coordinate authorization requests and obtain additional clinical review when necessary.
• Communicate coverage determinations to providers and members both verbally and in writing.
• Maintain accurate records and documentation while ensuring compliance with applicable guidelines and regulations.
• Monitor healthcare utilization and assist in ensuring appropriate use of medical services.

Member & Provider Support (Approximately 15%)

• Serve as a point of contact for members, providers, and healthcare facilities regarding benefit-related questions.
• Assist members in understanding available healthcare benefits and coverage options.
• Provide guidance on accessing participating providers and available healthcare resources.
• Address inquiries, resolve benefit-related concerns, and follow up on outstanding issues.
• Coordinate with internal departments to facilitate effective resolution of member and provider requests.

Care Coordination & Utilization Management (Approximately 15%)

• Monitor ongoing treatment plans and hospitalizations to support appropriate care management.
• Assist with transitions of care and post-discharge planning by providing benefit information and coverage guidance.
• Identify opportunities for additional support services and healthcare resources that may benefit members.
• Promote member engagement and informed healthcare decision-making.
• Collaborate with healthcare professionals and internal teams to support positive clinical and financial outcomes.

Qualifications

Required

• Active Registered Nurse (RN) license in the State of New Jersey.
• 3-5 years of recent clinical nursing experience, preferably in a medical-surgical or comparable setting.
• Strong assessment, critical thinking, and problem-solving abilities.
• Excellent verbal and written communication skills.
• Ability to manage multiple priorities in a fast-paced environment.
• Proficiency with Microsoft Office and electronic documentation systems.

Preferred

• Experience in prior authorization, utilization review, case management, care coordination, discharge planning, managed care, health insurance, or employee benefits.
• Familiarity with medical terminology, healthcare delivery systems, and clinical documentation practices.
• Exposure to healthcare benefits administration or insurance-related processes.
• Leadership, supervisory, or mentoring experience is a plus.