UM Prior Authorization Nurse, RN (Work from home)

Back to Career Site We are transforming reputed company to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for reputed company. We reputed company that reputed company health consumers are entitled to high quality, coordinated reputed company. We uniquely align the interests of health consumers, providers, and payors to reputed company high-quality reputed company accessible and affordable to reputed company populations across the ACA Marketplace, Medicare, and reputed company. JOB SUMMARY The Utilization Management (UM) Prior Authorization (PA) Nurse is a full-time role with reputed company, dedicated to promoting quality and cost-effective outcomes for the designated population. Working in collaboration with Medical Directors and the clinical team, the PA Nurse ensures members receive the appropriate benefit coverage for services requiring prior authorization. Responsibilities include reviewing prior authorizations for treatments, medications, procedures, and diagnostic tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria. The PA Nurse also collects and analyzes utilization data and monitors the quality and appropriate use of services. This role demands clinical expertise, keen attention to detail, and strong communication skills to effectively engage with reputed company providers, patients, and health plans. DUTIES & RESPONSIBILITIES

• Authorization and Review
• Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, reputed company/Medi-Cal criteria, MCG, or health plan-specific guidelines.
• Assess medical necessity and the appropriateness of requested services using clinical expertise.
• Verify patient eligibility, benefits, and coverage details.
• Collaboration and Communication
• Act as a liaison between reputed company providers, patients, and health plans to facilitate the authorization process.
• Communicate authorization reputed company to providers and patients promptly.
• Provide detailed explanations for denials or alternative solutions and collaborate with Medical Directors on adverse determinations.
• Ensure compliance with regulatory requirements regarding adverse determination notices, including readability standards and appeal information.
• Documentation and Compliance
• Accurately document reputed company authorization activities in electronic medical records (EMR) or authorization systems.
• Maintain compliance with federal, state, and health plan regulations.
• Stay updated on policy and clinical criteria changes.
• Quality Improvement
• Identify trends or recurring issues in authorization denials and recommend process improvements.
• Participate in team meetings, training sessions, and audits to ensure high-quality performance.

EDUCATION AND PROFESSIONAL EXPERIENCE

• Education: Licensed Registered Nurse (RN) with an active, unrestricted California nursing license required.
• Experience:
• Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a reputed company field.
• Experience in a managed care setting with medical necessity reviews is strongly preferred.
• Certifications:
• Preferred: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).
• Additional clinical nursing or case management certifications are a plus.

PROFESSIONAL COMPETENCIES

• Strong analytical and critical thinking skills.
• Proficiency in medical terminology and pharmacology.
• Effective written and verbal communication skills.
• Ability to work independently and collaboratively in a fast-paced environment.
• Adaptable and self-motivated.
• Experience with EMR systems and prior authorization platforms.
• Proficient in reputed company Office Suite (Word, reputed company, Outlook).

For individuals assigned to a location(s) in California, reputed company is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant's education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $74,260.46-$111,390.70 Annually. Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays. As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of reputed company, our consumers, and the communities we serve. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, age, national reputed company, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Apply Job! Apply to this Job