RN Prior Authorization Nurse

Daily Responsibilities Prior Auth RN:

• Position Purpose: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.

• Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations

• Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings

• Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care

• Educate providers on utilization and medical management processes

• Provide clinical knowledge and act as a clinical resource to non-clinical team staff

• Enter and maintain pertinent clinical information in various medical management systems