California Licensed Prior Authorization Nurse

Job Summary

A company is looking for a UM Prior Authorization Nurse, RN (Work from home).

Key Responsibilities

• Evaluate and process prior authorization requests based on clinical guidelines and assess medical necessity
• Act as a liaison between healthcare providers, patients, and health plans, communicating authorization decisions and compliance requirements
• Document authorization activities accurately and identify trends for quality improvement in the authorization process

Required Qualifications

• Licensed Registered Nurse (RN) with an active, unrestricted California nursing license
• Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review or case management
• Experience in a managed care setting with medical necessity reviews is preferred
• Preferred certifications include Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM)
• Additional clinical nursing or case management certifications are a plus