Key Responsibilities
Review prior authorization requests for outpatient and elective services in compliance with HIPAA.
Apply medical necessity criteria (Inter Qual, MCG, and/or client-specific guidelines).
Meet contractual turnaround time and productivity standards.
Request and evaluate clinical documentation as needed.
Approve cases within scope and escalate complex cases to the Medical Director.
Document clinical rationale and authorization decisions accurately.
Communicate effectively with providers, facilities, and internal teams.
Required Skills
Strong clinical judgment and ability to apply medical necessity criteria.
Excellent documentation, organizational, and time management skills.
Ability to interpret clinical records and identify missing information.
Proficiency with electronic documentation systems and MS Office.
Ability to work independently in a remote environment.
Strong written and verbal communication skills.
Adherence to HIPAA and confidentiality requirements.
Preferred Qualifications
Active, unrestricted RN license (compact preferred).
3–5 years of clinical nursing experience.
Medical necessity review and utilization management experience.
Managed care and CMS experience preferred.
Associate or Bachelor’s degree preferred.
