Prior Authorization Nurse, RN

This is a fully remote position, open to applicants in California.

📋 Description

• Evaluate and process prior authorization requests utilizing Medicare, Medicaid/Medi-Cal, MCG, and specific clinical guidelines from health plans.

• Assess the medical necessity and appropriateness of requested services.

• Verify patient eligibility, benefits, and coverage information.

• Act as a liaison between healthcare providers, patients, and health plans throughout the authorization process.

• Communicate authorization decisions in a timely manner.

• Clarify denials or alternative solutions and collaborate with Medical Directors regarding adverse determinations.

• Ensure adherence to regulatory standards concerning adverse determination notices, readability requirements, and appeal information.

• Document authorization activities within EMR or authorization systems.

• Maintain compliance with federal, state, and health plan regulations.

• Stay updated on changes in policy and clinical criteria.

• Identify trends in denials and suggest process enhancements.

• Participate in team meetings, training sessions, and audits.

⛳️ Requirements

• Must be a Licensed Registered Nurse (RN) with an active, unrestricted nursing license in California.

• A minimum of 2-3 years of clinical nursing experience is required.

• At least 1 year of experience in utilization review, case management, or a related field.

• Experience in a managed care environment with medical necessity reviews is highly preferred.

• Preferred certifications include Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).

• Strong analytical and critical thinking capabilities are essential.

• Proficiency in medical terminology and pharmacology is required.

• Excellent written and verbal communication skills are necessary.

• Ability to work independently as well as collaboratively in a fast-paced setting.

• Must be adaptable and self-motivated.

• Experience with EMR systems and prior authorization platforms is essential.

• Proficiency in Microsoft Office Suite (Word, Excel, Outlook) is required.

🏝️ Benefits

• Health benefits.

• Life and disability benefits.

• 401(k) savings plan with matching contributions.

• Paid Time Off.

• Paid holidays.

• Remote work arrangement.

• Some travel may be required.