Supporting the health plan's utilization management and prior authorization functions is the core of this nursing role. This includes inpatient care, outpatient services, medications, and durable medical equipment. The position suits a nurse who can review requests for eligibility, benefit coverage, medical necessity, and clinical appropriateness, escalating cases that require higher-level clinical review.
Responsibilities
Receive, review, and process utilization review and prior authorization requests across inpatient admissions and continued stays, outpatient services and procedures, diagnostic imaging, medications, and durable medical equipment (DME)
Verify member eligibility, benefit coverage, applicable limitations or exclusions, and authorization requirements in accordance with plan documents and policies
Obtain and review relevant clinical documentation, including history, diagnoses, treatment plans, test results, medication history, and supporting medical records needed to evaluate requests
Apply MCG (Milliman Care Guidelines), plan criteria, pharmacy/formulary requirements, and other approved clinical decision-support criteria, as applicable, to evaluate medical necessity and clinical appropriateness within the scope of the position
Approve requests that meet established criteria and delegated authority; refer requests that do not clearly meet criteria, involve complex clinical issues, or require physician review to the appropriate clinical reviewer or Medical Director
For inpatient reviews, evaluate admission information and continued-stay documentation, monitor authorized days and level of care, request additional clinical information when needed, and escalate cases involving extended stays, discharge barriers, or other clinical concerns
For outpatient reviews, evaluate requested procedures, therapies, imaging, and other services for benefit coverage, medical necessity, site of service, frequency, and applicable plan requirements
For medication reviews, evaluate prior authorization requests using applicable benefit, formulary, step-therapy, quantity-limit, and clinical criteria; obtain medication history and supporting documentation; and refer exceptions or complex requests for Medical Director review as appropriate
For DME reviews, evaluate requests for equipment and supplies for benefit coverage, medical necessity, appropriate coding, quantity/frequency, rental-versus-purchase requirements, and supporting documentation
Identify requests that may require additional coordination, including single-case agreements, specialty services, high-cost care, care management, or provider contracting, and route them to the appropriate internal resource
Summarize clinical information and document the rationale supporting authorization, modification, referral, or other disposition in a clear and concise manner
Maintain accurate and timely case notes, authorization records, status updates, and supporting documentation in the utilization management system
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Communicate authorization status, requests for additional information, and determinations clearly, professionally, and within required timeframes to providers, members, and internal stakeholders
Contact provider offices and facilities to obtain missing or incomplete clinical information and follow up as needed to support timely review
Explain utilization management processes, plan requirements, and documentation expectations while avoiding interpretation outside the scope of the position
Respond to authorization-related questions, issues, and escalations promptly and route clinical, benefit, or appeal questions to the appropriate resource when necessary
Perform reviews in accordance with plan policies, HIPAA requirements, applicable federal and state requirements, and relevant accreditation standards, including URAC and NCQA requirements as applicable to the health plan
Monitor and meet required turnaround times for routine, urgent, concurrent, and retrospective reviews, as applicable
Maintain complete, accurate, and audit-ready documentation of review activities, communications, clinical information, and decision rationale
Support quality assurance activities, audits, and process improvement efforts related to utilization management and prior authorization
Collaborate with Care Coordination/Case Management, Claims, Member Services, Contracting/Provider Relations and the Medical Director to support coordinated and efficient review processes
Identify recurring utilization patterns, documentation issues, provider concerns, or workflow opportunities and share observations with leadership
Participate in team meetings, training, policy updates, and ongoing professional development to maintain knowledge of plan benefits, clinical criteria, coding, and utilization management practices
Perform other related duties as assigned to support health plan operations
Requirements
Associate or bachelor’s degree in a healthcare-related field preferred
Certified Medical Assistant (CMA) or other clinical paraprofessional credential with relevant utilization management experience may be considered
Minimum of two years of experience in utilization review, prior authorization, medical office operations, pharmacy authorization, DME authorization, medical billing, or a related payer or provider setting
Familiarity with MCG, InterQual, or comparable clinical decision-support criteria preferred
Working knowledge of medical terminology and CPT, HCPCS, and ICD-10 coding
Familiarity with medication formularies and common DME coding is desirable
Strong critical-thinking and analytical skills with the ability to interpret clinical documentation, apply established criteria, and recognize when escalation is required
Ability to distinguish clinical review requirements from benefit and coverage requirements and apply both accurately
Excellent verbal and written communication skills, including the ability to communicate effectively with provider offices, facilities, members, and internal teams
Exceptional attention to detail, organization, follow-through, and ability to manage multiple reviews with competing deadlines
Ability to maintain confidentiality and exercise sound judgment when handling protected health information and sensitive member information
Proficiency in Microsoft Office applications, including Word, Excel, and Outlook
Experience working with electronic utilization management, claims, electronic health record, or related healthcare systems
Benefits
Health insurance with no employee-paid premium, deductible, coinsurance, or copays for in-network providers
Health benefits cover employees and eligible family members
On-site clinic for employees and family members (100% covered)
401(k) with up to 8% employer contributions
Annual discretionary bonus eligibility
Dental, life, and vision insurance
Paid time off
Health and dependent care flexible spending accounts
Continuous professional development opportunities
Important Details
Schedule: Regular working hours are 8:00 a.m. to 5:00 p.m., Monday through Friday
About the Company
The company supports the health plan's utilization management and prior authorization functions.