Precertification Nurse RN
Location: Springfield, NJ
Work Arrangement: 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)
Experience: 3–5 years of recent clinical nursing experience
License: Active New Jersey RN license
Position Overview
Join a well-established employee benefits organization providing healthcare and insurance support services to its membership population. This is a non-bedside nursing role focused on precertification, clinical review, utilization management, care coordination, and member support.
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 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 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.
• Promote member engagement and informed healthcare decision-making.
• Collaborate with healthcare professionals and internal teams to support positive clinical and financial outcomes.
Required Qualifications
• Active RN license in the State of New Jersey.
• 3–5 years of recent clinical nursing experience , preferably medical-surgical or comparable.
• Strong assessment, critical thinking, and problem-solving skills.
• 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 Qualifications
• Experience with 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.
...Job Description Kitchen Designers at The Home Depot help customers turn their kitchen and bath dreams into reality. Kitchen Designers greet and engage customers, listen to their needs, and guide them through the design process-offering 'good, better, best' options,...
...Job Description Job Description Aerospace Painter / Finishing Technician Location: Redmond, WA Pay: $22.00-$25.00/hour Shift Options: ~1st Shift: 5:30AM-2:00PM, Monday-Friday ~2nd Shift: 2:30PM-11:00PM, Monday-Friday ~ Voluntary Saturday Overtime Available...
...Reporting to the Team Leader, US Operations, the Ticketing Specialist is responsible for applying consistently high levels of customer service to The Allstars Travel Group Corporate Clients; accurately managing all queues and email requests by following established processes...
...energetic and fun people to join our team in Morehead. We are hiring hourly Assistant Managers for the morning, afternoon, and evening shifts. Weekend availability is a must. We offer a competitive starting wage and many opportunities for advancement. We are growing, and...