Prior Authorization Nurse

About This Role As a Utilization Review Registered Nurse (RN) supporting a health plan or insurance organization, you will use your clinical expertise to evaluate the medical necessity, appropriateness, and efficiency of healthcare services requested by providers. You'll serve as a critical liaison between healthcare providers and the health plan—helping to ensure that members receive the right care, in the right setting, at the right time. This role is a blend of clinical decision-making and administrative coordination, requiring strong communication skills and a solid understanding of medical guidelines and coverage policies. Responsibilities • Review prior authorization requests and clinical documentation to determine medical necessity and appropriate level of care. • Apply utilization review criteria (e.g., InterQual, MCG) and plan policies to support coverage decisions. • Collaborate with physicians, providers, and internal teams to obtain necessary documentation and clarify clinical details. • Communicate determinations clearly and professionally to providers and members. • Identify and escalate cases requiring physician review or medical director input. • Document all review activities and decisions in accordance with regulatory and organizational standards. • Participate in quality initiatives, audits, and policy updates to support continuous improvement. Required Qualifications • Current RN license • BLS (other certifications as required by facility) • Two years of recent Utilization Review RN experience • Strong communication and adaptability skills Apply tot his job Apply To this Job