Job Description

The Prior Authorization RN (Registered Nurse) evaluates documentation for medical necessity of medical services and procedures according to Medicare guidelines. This role applies clinical judgment to documentation and renders a provisional coverage decision. The Prior Authorization RN will work alongside Senior Nurse Analysts to ensure that accurate clinical judgement is given based on national and local coverage determinations and direction from CMS to prevent unnecessary procedures and treatments. The Prior Authorization RN will conduct thorough reviews of submitted clinical documentation to ensure that services are medically necessary in accordance with Medicare policies and guidelines. They will verify that all documentation is complete and compliant before services are rendered, ensuring accurate submission for prior authorization. They will write clear, concise, and accurate decision letters for healthcare providers that explain the rationale for provisional coverage determinations. Responsibilities: Conduct thorough reviews of submitted clinical documentation to ensure that services are medically necessary in accordance with Medicare policies and guidelines. Verify that all documentation is complete and compliant before services are rendered, ensuring accurate submission for prior authorization. Write clear, concise, and accurate decision letters for healthcare providers that explain the rationale for provisional coverage determinations. Review and assess educational materials and national and local coverage determinations, to ensure that documentation requirements are fully understood and met. Ensure that prior authorization requests are submitted with the appropriate supporting information, aligned with Medicare criteria. Maintain consistent communication with Senior Nurse Analysts to seek further education and clarification on complex cases and guidance on policy interpretation. Collaborate with Senior Nurse Analysts and supervisors to resolve provider-related inquiries and enhance the overall workflow of the prior authorization process. Qualifications: Associate’s Degree in Nursing or Bachelor’s Degree in Nursing (BSN). Active Registered Nurse (RN) license in state of practice or a compact nursing license. 3 or more years of clinical nursing experience such as inpatient or outpatient settings, acute care, home health, hospice, utilization management, case management, or managed care. Solid knowledge and understanding of prior authorization, utilization review, and relevant clinical guidelines. Familiarity with regulatory standards. Strong critical thinking and clinical decision-making skills. Ability to work independently, applying sound nursing judgment, critical reasoning, and creative problem-solving. Strong organizational skills with the ability to meet deadlines, manage competing priorities, and maintain quality standards. Exceptional written and verbal communication skills with the ability to communicate complex medical information clearly and concisely. What We Offer: Remote and hybrid work options available. Performance bonus and/or merit increase opportunities. 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately). Competitive paid time off. Health insurance, dental insurance, and telehealth services start DAY 1. Professional and Leadership Development Programs. #J-18808-Ljbffr WPS—A health solutions company

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