Prior Authorization/Clinical Review Nurse (RN)

About the role

The Prior Authorization/Clinical Review Nurse (RN) plays a crucial role in ensuring patients have access to necessary medications and therapies. This position requires strong clinical knowledge, excellent communication skills, and an understanding of insurance policies and medical necessity criteria.

Responsibilities

• Review patient clinical documentation and verify medical necessity for prior authorization requests in alignment with payer policies and clinical guidelines
• Prepare and submit prior authorization requests for specialty medications, infusions, and related therapies
• Communicate with insurance companies, physician offices, and internal departments to resolve authorization issues and obtain approvals
• Provide clear updates to patients and care teams on the status of prior authorizations
• Document all interactions, decisions, and follow-up actions in the patient record and electronic systems
• Stay current on payer requirements, formulary changes, and industry regulations affecting prior authorization processes
• Maintain patient confidentiality and comply with HIPAA regulations
• Participate in quality improvement initiatives related to the authorization workflow

Requirements

• Active, unencumbered Registered Nurse (RN) license in Illinois
• Associate degree
• 2+ years of clinical nursing experience
• 1+ year of experience in prior authorization, utilization review, case management, or a related role
• Strong knowledge of insurance plans, payer authorization requirements, and medical necessity criteria
• Proficiency in EMR/EHR and pharmacy benefit management systems
• Excellent communication and critical thinking skills

Qualifications

• Preferred: Experience in specialty pharmacy, infusion services, or rare disease care coordination
• Preferred: Prior work in a managed care or payer environment
• Preferred: Prior experience with CoverMyMeds for clinical question submissions

Skills

• Strong knowledge of insurance plans, payer authorization requirements, and medical necessity criteria
• Proficiency in EMR/EHR and pharmacy benefit management systems
• Excellent communication and critical thinking skills

Benefits

We offer a comprehensive benefits package designed to support your health, financial security, and overall well-being:

• Medical Coverage, Dental, and Vision Coverage
• 401(k) with employer match
• Accident and Critical Illness coverage
• Generous PTO, paid holidays, and floating holidays
• Company-paid life insurance options
• Tuition reimbursement program

Pay

$80,000 annually

Schedule

Based out of Elk Gove Village