Pre-Authorization Nurse
Core
Reviews prior authorization requests for appropriate care and setting, completing medical necessity and level of care reviews using clinical judgment.
Role type
Pre-Authorization Nurse (Utilization Management)
Builds
Approved services and care plans for insurance members
Domain
Healthcare insurance / Utilization Management
Required skills
Clinical judgment, Utilization management, Case management, Discharge planning, Home health, MS Office proficiency, Independent decision making
Preferred skills
Bachelor's degree, MCO experience, Health Plan experience, Medicare/Medicaid experience, Outpatient experience, MCG or Interqual guidelines experience
Responsibilities
Review prior authorization requests, Complete medical necessity reviews, Educate providers on utilization processes, Enter and maintain clinical information in medical management systems, Make decisions regarding work methods in ambiguous situations
Seniority
Mid-level, independent contributor