Join Provider Resources (PRI) and Make an Impact in Healthcare!
At PRI, we’re passionate about driving integrity and advancing quality across the healthcare system. As a trusted leader in the industry, we’re tackling some of healthcare’s biggest challenges—improving compliance, advancing health equity, and enhancing quality and clinical outcomes while helping organizations improve care delivery and create meaningful change.
We believe that people are at the heart of healthcare, and focus on scalable, person-centered strategies that prioritize clinical excellence and evidence-based practices. Our work supports a broad network of stakeholders, including providers, patients, caregivers, payers, and regulators. We strive to enhance experiences, improve outcomes, and foster a healthier future for all.
If you’re looking to be part of a forward-thinking team that makes a difference, PRI is the place for you!

SKILLS:

• Proven experience building and managing operational processes and teams.
• Strong analytical skills with the ability to track metrics, identify trends, and make datadriven decisions.
• Excellent written and verbal communication skills, with the ability to interact professionally with all levels of staff and external stakeholders.
• Expertise in clinical guidelines (e.g., MCG, InterQual), healthcare regulations (e.g., ACA, ERISA), and IRO accreditation standards (e.g., URAC).
• High level of integrity, objectivity, and accountability.
• Other Requirements: Ability to obtain and maintain U.S. Government Security Clearance.

OPERATIONAL AND CLINICAL RESPONSIBILITIES

• Conduct independent clinical reviews of medical records, appeals, and prior authorization requests to determine medical necessity and appropriateness of care.
• Apply evidencebased guidelines, clinical criteria (e.g., MCG, InterQual), and regulatory standards to all reviews.
• Prepare clear, concise, and defensible written summaries and recommendations for each case reviewed.
• Collaborate with physician reviewers and other clinical staff to ensure a comprehensive and consistent review process.
• Maintain a current, unrestricted RN license.
• Stay current on clinical guidelines, regulatory changes, and payer requirements related to internal and external review processes.
• Participate in audits, training, and continuous quality improvement initiatives.