Outpatient Prior Authorization Nurse

About the role

We are seeking an Outpatient Prior Authorization Nurse to review authorization requests, ensure medical necessity, and support cost-effective patient care. The role involves applying clinical criteria, documenting decisions, and collaborating with clinical staff to coordinate care.

Key responsibilities

• Perform timely reviews of prior authorization requests using appropriate clinical criteria and national standards.
• Document approvals with clear rationale and maintain accurate records in the authorization system.
• Prepare case summaries and clinical criteria for requests that require physician review.
• Collaborate with multidisciplinary teams to coordinate patient care and ensure cultural sensitivity.
• Enter and update clinical information in authorization databases.
• Adhere to payroll policies, attendance standards, HIPAA regulations, and compliance plans.
• Participate in special projects and perform other duties as assigned.

Required profile

• High school diploma or equivalent.
• Minimum one year of experience in a clinical nursing setting.
• Prior authorization experience preferred.
• Ability to read, write, and speak English fluently.
• Commitment to confidentiality, privacy, and professional interaction with patients and staff.

Required skills

• Utilization Management principles.
• Prior Authorization processes.
• Familiarity with Medi-Cal guidelines.
• Familiarity with Medicare guidelines.