The clinician reviews prior authorization requests for procedures, medications, and diagnostic services, using medical necessity criteria to help determine coverage for a defined member population. This role also involves communicating decisions to providers and patients, documenting reviews in EMR or authorization systems, and working with medical directors on complex or adverse determinations. The work is fully clinical-administrative and centered on utilization management, compliance, and quality improvement in a value-based care environment.
Key Responsibilities
- Evaluate and process prior authorization requests for services, medications, and procedures using clinical guidelines and plan-specific criteria.
- Verify member eligibility, benefits, and coverage details before completing reviews.
- Assess medical necessity and appropriateness of requested services using clinical knowledge and evidence-based criteria.
- Communicate authorization decisions, denials, and alternative options to providers and patients in a timely manner.
- Collaborate with medical directors on adverse determinations and related notice requirements.
- Document authorization activities accurately in the EMR or authorization management system.
- Monitor denial trends and participate in quality improvement, audits, and team meetings.
- Maintain compliance with federal, state, and health plan requirements, including appeal and member communication standards.
Required
- Active California Registered Nurse (RN) license.
- Minimum 2 years of clinical nursing experience.
- Experience in utilization management, case management, or prior authorizations preferred as part of the required background.
- Working knowledge of insurance authorization processes and medical billing/coding concepts.
- Familiarity with MCG, InterQual, or NCQA standards.
Preferred
- Bachelor of Science in Nursing (BSN).
- Managed Care Nursing (CMCN) certification.
- Experience with EMR systems and prior authorization platforms.
- Experience using ICD-10 and CPT codes.
Benefits & Perks
- Full-time employment.
- Opportunity to work in a value-driven, coordinated care model.
- Work with medical directors and a broader clinical team.
- Exposure to utilization management, quality review, and compliance workflows.