This full-time RN role focuses on reviewing prior authorization requests for medications, procedures, diagnostic tests, and other services to determine medical necessity and coverage. The work is centered on managed care populations and requires regular coordination with Medical Directors, providers, patients, and health plans. Most duties are performed remotely, with some travel possible, and the role includes documentation, compliance, and utilization review support.
Key Responsibilities
- Evaluate and process prior authorization requests using Medicare, Medicaid/Medi-Cal, MCG, and health plan-specific guidelines.
- Assess medical necessity and the appropriateness of requested services.
- Verify patient eligibility, benefits, and coverage details.
- Communicate authorization decisions, denials, and alternative options to providers and patients.
- Collaborate with Medical Directors on adverse determinations and escalated reviews.
- Document authorization activity in EMR and prior authorization systems.
- Maintain compliance with federal, state, and health plan regulations.
- Identify denial trends and participate in quality improvement, audits, and team training.
Required
- Active, unrestricted California RN license.
- Minimum of 2-3 years of clinical nursing experience.
- At least 1 year of experience in utilization review, case management, or a related field.
- Experience with medical necessity reviews in a managed care setting.
Preferred
- Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).
- Additional clinical nursing or case management certifications.
- Experience with EMR systems and prior authorization platforms.
- Experience in a fast-paced managed care environment.
Benefits & Perks
- Remote work for most responsibilities.
- Health, life, and disability benefits.
- 401(k) savings plan with match.
- Paid time off and paid holidays.
- Annual salary range provided for California-based employees.