Prior Authorization Nursing Jobs
What is a Prior Authorization Nurse?
A Prior Authorization Nurse is a licensed registered nurse who specializes in reviewing and evaluating medical service requests to determine whether they meet criteria for insurance coverage before care is provided. This role is part of prospective utilization management, meaning it occurs before treatment begins, and is essential for ensuring that patients receive medically necessary services while controlling healthcare costs.
What does a Prior Authorization Nurse do?
Key job responsibilities for a prior authorization nurse may include:
Perform clinical reviews of authorization requests using appropriate criteria
Provide accurate and complete documentation with rationale used to approve request
Collaborate with various staff within provider networks and case management team coordinate patient care
Equip and train prior authorization tech with needed resources
Ability to multitask between computer and multi-line phone requests
Participate in interdepartmental projects when needed
Enter and maintain clinical information in multiple health management systems
How to Work as a Prior Authorization Nurse
The purpose of the prior authorization nurse is to provide timely review of authorization requests and ensure the requests meet national standards and contractual requirements. The prior authorization nurses will also promote the quality and cost effectiveness of patient care using clinical acumen. Additionally, the nurses will prepare documentation, perform audits of patient records, and assist management as needed.
Skills and qualifications needed:
Bachelor’s or Associate Degree in Nursing (Bachelor’s preferred)
State licensure as a Registered Nurse (RN)
Minimum of two (2) years of experience in acute clinical nursing setting
Knowledge of utilization management and case management principles preferred
Prior authorization experience preferred
Advanced verbal, written communication and organization skills
Knowledge of Microsoft Word and basic computing systems
Drive to work well with a team
Strong service orientation and professionalism
Where Do Prior Authorization Nurses Work?
Prior authorization nurses are found in a variety of healthcare environments, including but not limited to:
Managed care organizations
Hospitals and health systems
Outpatient clinics
Specialty practices (e.g., oncology, cardiology)
Pharmacy benefit management companies
Telehealth and virtual care platforms
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