Hybrid Prior Authorization RN

Prior Authorization RN

Responsibilities

• 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