RN- Prior Authorization

Job Scope

Nurse Clinician/Registered Nurse II is responsible for reviewing clinical criteria reviews for providers, members and patient client advocates within the Prior Authorization/Utilization Management Team.

Follows department standard operating procedures, while performing Utilization Management.


* Maintain a professional and ethical behavior at all times as outlined by the Nurse Practice Act and applicable company policies.


* Review clinical information and apply the health plan's guidelines/criteria to determine medical necessity of a requested


* service and initiate a medical review to submit to the Medical Director if the requested service does not meet the health plan


* guidelines or criteria.


* Document nursing notes in the system that include a medical review of the clinical information that


* was submitted with the requested service and apply the appropriate medical policy or criteria to render


* a decision.


* Resolve inquiries from providers and members regarding decision outcomes and direct on next steps.


* Provide feedback to the clinical team leaders on process improvements to help streamline the


* clinician review process in order to ensure patients are serviced accurately and timely.


* Establish and maintain solid working relationships with all operational stakeholders, including


* internal business partners within the organization.


* Perform other duties and special projects as assigned.

Minimum Qualifications


* Nursing degree, BSN Preferred


* 2-5 years experience in a clinical setting.

Experience in Specialty Infusion Treatments or with Oncology population strongly preferred


* Experience working with utilization management in an insurance environment preferred


* Licensures/Certifications: Unencumbered, Registered Nursing Licensure


* Knowledge and Abilities:


* Previous clinical criteria review experience preferred.


* Active professional affiliations and/or national certification in related clinical specialty preferred


* Able to work flexible work schedule

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an hourly rate of 32 - 54 USD / hourly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure.

That's why you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health.

Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs.

We also offer 401(k) with company match, company paid life insurance, tuition ...