Prior Authorization Nurse
POSITION OVERVIEW:
The Prior Authorization Nurse plays a critical role in ensuring timely and accurate authorization of medical services across multiple specialties. This position serves as a liaison between providers, patients, and insurance companies to facilitate timely access to care while ensuring compliance with payer guidelines. The nurse utilizes clinical knowledge and judgment to evaluate medical necessity, gather supporting documentation, verifying insurance requirements and submitting prior authorization requests for multiple specialties. Working collaboratively with physicians, clerical staff, and other departments, the Prior Authorization Nurse helps streamline workflows, reduce delays in care, and optimize reimbursement.
QUALIFICATIONS:
- Current Registered Nurse (RN) license in IA preferred. Licensed Practical Nurse (LPN) applicants with relevant prior authorization experience will also be considered
- 2+ years of clinical nursing experience
- Prior experience in utilization review, case management, or prior authorization preferred
- Strong knowledge of payer policies and clinical criteria (e.g., InterQual, MCG)
- Experience in one or more of the following specialties: oncology, radiology, infusion therapy, pain management procedures or surgical services
- Experience with Microsoft Office, Excel and other web-based programs including CoverMyMeds
- Excellent communication, organizational and time management skills
ACCOUNTABILITY:
Reports to the Prior Authorization Manager and Revenue Cycle Director
DIRECT REPORTS:
None
POSITION-SPECIFIC REQUIREMENTS:
- Review clinical documentation to determine medical necessity for requested services.
- Submit prior authorization requests to insurance companies using payer-specific portals and Epic workflows.
- Communicate with providers to obtain additional documentation or clarify orders as needed.
- Track and follow up on pending authorizations to ensure timely responses.
- Document all authorization activity in the electronic health record (Epic).
- Collaborate with other team members to ensure complete and accurate submissions.
- Stay current with payer guidelines, authorization requirements, and regulatory changes.
- Escalate denials or delays to appropriate clinical or administrative leadership.
- Coordinate and schedule peer-to-peer (P2P) reviews between providers and payers to address clinical denials.
- Submit formal appeals for denied services, ensuring compliance with payer-specific guidelines and timelines
- Participate in process improvement initiatives to streamline authorization workflows.
- Perform additional responsibilities as requested by leadership to support departmental goals and hospital operations
WORK ENVIRONMENT:
- Works in a well-illuminated, climate-controlled environment
- May come in contact with hazardous chemical or treatment modalities
- Possibility exists of exposure to communicable diseases
- Involvement in inpatient care may result in unavoidable work-related illness or injury
- Work environment is comfortable, with minimal exposure to physical hazards
- Moderate to loud noise environment when machines/equipment in use
- Involvement in checking in/moving of supplies may result in unavoidable work-related injury
- Must be constantly alert for patient/family emergency situations
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