Prior Authorization Clinician

Job Description

• The Prior Authorization Clinician reviews inpatient, outpatient, and home care service requests to determine medical necessity, using evidence-based guidelines such as InterQual and medical policies. The clinician performs pre-certification, concurrent, and retrospective reviews while ensuring timely, accurate, and compliant decisions.
• Key Responsibilities:
• Review clinical documentation and determine medical necessity for requested services.
• Apply InterQual, medical policies, and benefit guidelines to authorization decisions.
• Perform prior authorization, utilization review, and retrospective reviews.
• Document and communicate review outcomes with providers and internal teams.
• Refer cases to Physician Reviewers when medical necessity criteria are not met.
• Ensure reviews meet Medicaid, ACA, CMS, and NCQA turnaround requirements.
• Identify opportunities for process improvement and quality improvement.
• Participate in audits, team meetings, training, and orientation of new nurses.
• Work independently in a fully remote environment while meeting productivity and quality standards.
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• Critical Must-Have Experience
• Candidates must have BOTH:
• Outpatient Home Care Experience: Direct experience working with home care patients, such as visiting nurse/home health experience.
• Payor-Side Prior Authorization Experience: Prior authorization experience on the insurance/health-plan side, reviewing clinical documentation against medical criteria to determine whether services can be approved.
• Qualifications
• RN license, active and unrestricted in MA, NH, or a compact state.
• Nursing degree/diploma required; BSN preferred.
• 2+ years of prior authorization/utilization review experience.
• Experience with InterQual/evidence-based guidelines.
• Managed care experience preferred.
• Medicare and Medicaid knowledge preferred.
• Strong clinical judgment, critical thinking, communication, organization, and time-management skills.

Job Requirements

Clinical Documentation Review, Medical Necessity Determination, InterQual, Evidence-Based Guidelines, Medical Policies, Benefit Guidelines, Prior Authorization, Utilization Review, Pre-Certification, Concurrent Review, Retrospective Review, Provider Communication, Medicaid, ACA, CMS, NCQA, Process Improvement, Quality Improvement, Audits, Home Care, Outpatient Care, Payor-Side Prior Authorization, Managed Care, Medicare, Clinical Judgment, Critical Thinking, Communication, Organization, Time Management

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