Prior Authorization RN

Brief Company Overview & Sells:

A growing healthcare organization focused on delivering high-quality, patient-centered care management and utilization services across complex patient populations. This is an opportunity to join a collaborative clinical team with a hybrid work model, strong leadership support, and a focus on improving care coordination and healthcare outcomes.

Job Description:

The Prior Authorization RN is responsible for reviewing and determining prior authorization requests for medical services, procedures, medications, and diagnostic testing. This role ensures requests are evaluated for medical necessity, appropriateness of care, and compliance with evidence-based guidelines and regulatory requirements. This position works closely with providers, clinical teams, and utilization management leadership to support timely authorization decisions, coordinated care delivery, and effective utilization of healthcare resources.

Key responsibilities include:

Reviewing prior authorization requests for inpatient, outpatient, procedural, diagnostic, and pharmacy-related services Applying clinical guidelines including MCG criteria, CMS determinations, and payer policies Reviewing medical records and clinical documentation to support authorization decisions Collaborating with physicians, providers, and internal teams to obtain necessary clinical information Supporting denial management, appeals, and peer-to-peer review processes Ensuring compliance with turnaround times, regulatory standards, and documentation requirements Identifying opportunities to improve workflows and operational efficiency

Qualifications:

Active RN license required BSN preferred 2-3+ years of clinical nursing experience required, preferably in acute care Prior experience in utilization management, prior authorization, or case management required Strong knowledge of MCG guidelines and utilization review processes preferred Excellent communication, critical thinking, and organizational skills Experience working with physicians, payers, or managed care organizations preferred

Compensation:

$95,000 - $105,000 base salary plus bonus potential