Prior Authorization RN

Description

JOB SUMMARY

The Prior Authorization Registered Nurse is responsible for performing clinical review, analysis, and evaluation of authorization requests to determine medical necessity, appropriate utilization, and compliance with health plan and regulatory standards. The RN conducts prospective concurrent, and retrospective review of medical services including specialty care, diagnostic procedures, post-acute services, elective admissions, and out-of-network referrals.

The Prior Authorization RN applies advanced clinical judgment, utilizes standardized criteria sets (MCG, InterQual, CMS guidelines), and collaborates with providers, health plans, and internal clinical teams to facilitate timely, safe, and appropriate care coordination. The RN serves as a clinical resource for Prior Authorization Coordinators and supports the organization’s Utilization Management goals, quality standards, and regulatory compliance.

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Graduate of an accredited Registered Nursing program.

Preferred: Bachelor’s degree in Nursing or related field.

Experience

Minimum: 2+ years of clinical experience in an acute or ambulatory care setting. Knowledge of medical terminology, clinical documentation, and care delivery systems.

Preferred: 1+ years of experience in Utilization Management, Prior Authorization, Case Management, or Managed Care. Experience   with MCG, InterQual, or similar criteria-based tools. Experience in MSO, IPA, ACO, medical group, or health plan environments. Working knowledge of CPT, HCPCS, and ICD-10 coding. Experience with EMR and UM systems.

Certification(s)

Current State Registered Nursing License

Preferred: Certified Case Manager (CCM), Accredited Case Manager (ACM), or UM-related certifications.

Skills, Knowledge & Abilities

· Strong knowledge of utilization management principles, medical necessity criteria, and managed care processes.

· Proficiency in interpreting clinical documentation and applying evidence-based review criteria.

· Strong verbal and written communications skills, with ability to communicate effectively with physicians and interdisciplinary teams.

· Excellent organizational, time-management, and prioritization skills.

· Ability to maintain professionalism, confidentiality, and sound clinical judgment.

 PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. This position requires prolonged period of sitting, typing, and computer work, with occasional standing, walking, bending, and reaching. The role involves the ability to lift up to 20 pounds occasionally and to maintain concentration for extended periods while reviewing complex clinical documentation. The employee must be able to manage multiple priorities and deadlines while exercising sound clinical judgment and decision-making skills. The work environment may be office-based or hybrid, with frequent communication occurring via phone and electronic methods with internal staff and healthcare providers. Noise levels in the work setting are typically low to moderate.