Prior Authorization Nurse

We’re looking for experienced RNs with strong payer-side prior auth experience to support utilization management and ensure guideline compliance. In this role, you will be responsible for ensuring that patients receive the necessary approvals for medical services and procedures before they are provided. You will work closely with healthcare providers, insurance companies, and patients to facilitate the authorization process while adhering to all regulatory guidelines.

Review and process pre-service authorization requests Apply CMS, MCG, InterQual, and health plan-specific guidelines to evaluate medical necessity Collaborate with providers and internal departments to ensure timely decisions Document all decisions in Care Management platforms (e.g., ZeOmega, CareWebQI) Support CMS audit readiness and compliance standards Review and process prior authorization requests for medical procedures and services. Verify insurance coverage and eligibility for patients. Obtain and organize relevant medical records and documentation to support authorization requests. Communicate effectively with healthcare providers, insurance representatives, and patients regarding the status of authorizations. Ensure compliance with HIPAA regulations and maintain confidentiality of patient information. Utilize medical coding knowledge, including ICD-10 and ICD-9, to accurately document diagnoses and procedures. Stay updated on managed care policies and changes in insurance regulations that may affect authorization processes. Maintain accurate records of all authorization requests and outcomes in the office system.