Registered Nurse

Position: Prior Authorization Nurse

Overview: As a Prior Authorization Nurse, you will work in a specialized area outside of a hospital setting, focusing on utilization management and prior authorization reviews. Your role involves building strong relationships with healthcare providers and medical directors by reviewing member clinical information, applying relevant criteria, and making authorization decisions according to company policies and procedures. You will also document patient care activities and communication with providers and medical directors. The position requires working Monday through Friday, from 8 am to 5 pm EST, with occasional weekend on-call rotations.

Key Responsibilities

• Develop strong relationships with healthcare providers and medical directors through thorough review of member clinical information and application of authorization criteria.
• Make authorization determinations based on company policies, federal/state regulations, MCG guidelines, and internal criteria.
• Accurately document patient care activities, communications with providers and medical directors, and authorization decisions.
• Ensure all activities comply with company procedures and quality standards.
  
  

Qualifications

• Licensure: Current Registered Nurse (RN) license in the state of employment; additional licensure may be required for multi-state service areas.
• Experience: At least 3 years of nursing experience, including a minimum of 1 year in Utilization Management Prior Authorization.
• Education: RN Diploma, Associate's Degree, or Bachelor’s Degree in Nursing.
• Skills: Advanced computer proficiency, excellent written and verbal communication skills, and strong customer service abilities.
  
  

Physical Demands

• Frequent use of hands for typing and working on a computer.
• Ability to sit for extended periods while working at a computer and monitor.
• Vision requirements include close vision, color vision, night vision, peripheral vision, depth perception, and the ability to adjust focus.
  
  

Additional Notes

• Proficiency in computer skills is essential.
• Strong customer service skills, both written and verbal, are crucial for success in this role.
  
  

Skills: licensure requirements,verbal communication,clinical information review,patient care documentation,communication with healthcare providers,written communication,management,customer service skills,computer proficiency,authorization criteria application,utilization management,prior authorization,utilization,authorization,patient care,medical directors