Nurse Case Manager, Prior Authorization RN

Position Summary: The Nurse Case Manager, Prior Authorization RN is responsible for reviewing and processing prior authorization requests for medical services, ensuring that all clinical criteria and health plan requirements are met. This role reports to the Manager of Inpatient Utilization Management and involves collaborating with healthcare providers, patients, and internal teams to determine the medical necessity of requested services, ensuring compliance with insurance guidelines, and maintaining accurate documentation. The Nurse Case Manager, Prior Authorization RN will support the goal of delivering timely and efficient authorization decisions while promoting quality patient care.

Essential Position Functions/Responsibilities:

• Review incoming prior authorization requests for medical services, including procedures, medications, and diagnostic tests, ensuring that they meet clinical guidelines and health plan requirements.

• Evaluate medical records, clinical documentation, and provider notes to determine the medical necessity and appropriateness of requested services based on established criteria.

• Communicate with healthcare providers, including physicians and specialists, to obtain additional information or clarification needed to process prior authorization requests.

• Work closely with other teams, such as utilization management, care management, and pharmacy, to ensure accurate and timely processing of prior authorization requests.

• Ensure all prior authorization processes comply with relevant healthcare regulations, health plan policies, and turnaround time standards.

• Accurately document the review process, decisions, rationale, and outcomes of prior authorization requests, maintaining clear and comprehensive records in the system.

• Support the review and resolution of denied prior authorization requests, including assisting with the preparation of information for appeals, when necessary.

• Educate healthcare providers and patients on the prior authorization process, required documentation, and health plan requirements.

• Assist in identifying opportunities for process improvements in the prior authorization workflow to increase efficiency and reduce errors.

• Ensure that prior authorization requests are processed within designated time frames to meet regulatory and health plan requirements.

Qualification Requirements:Skills/Knowledge/Abilities

• Strong understanding of clinical procedures, diagnoses, and treatments, with the ability to assess medical necessity based on evidence-based guidelines (MCG, National Coverage Determinations and Local Coverage Determinations).

• Excellent written and verbal communication skills, particularly in interacting with healthcare providers and patients in a professional and clear manner.

• Ability to manage multiple requests simultaneously while maintaining a high level of accuracy and efficiency.

• Strong critical thinking and decision-making skills to evaluate requests and address issues related to medical necessity and health plan compliance.

• Understanding of the prior authorization process, including guidelines, clinical review criteria, regulatory requirements and turnaround time expectations.

• Ability to adapt to changing health plan requirements, clinical criteria, and workflow processes.

Training/Education:

• Registered Nurse (RN) with an active and unrestricted nursing license in the state of practice required; Bachelor’s degree in Nursing (preferred).

Experience:

• At least 2-3 years of clinical nursing experience, with at least 1 year in utilization management, prior authorization, or a related healthcare setting.

• Experience in reviewing medical records, clinical documentation, and prior authorization requests.

• Familiarity with clinical decision-making criteria and evidence-based guidelines used in the prior authorization process (preferred).

Base Compensation; $90,000 – 105,000 annually

HealthCare Partners, MSO provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, HealthCare Partners, MSO complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.