Clinical Authorization Specialist

loganhealth; United States; Hybrid; USD 70,000 - 90,000; Full time

Job summary

Logan Health RN sought as Clinical Authorization Specialist to support medical necessity reviews, prior authorizations, and payer denial management for assigned services and treatments.

This hybrid role requires collaboration with clinic leadership, providers, nursing staff, and interdisciplinary teams to facilitate timely approvals and ensure accurate documentation and communication of outcomes.

Qualifications

• Current Montana RN license or multistate compact license with authorization to practice nursing in Montana.
• Associate Degree in Nursing required; Bachelor of Science in Nursing preferred.
• Minimum three (3) years of clinical nursing experience in acute care, ambulatory, specialty clinic, infusion, oncology, case management, utilization management, care coordination, or a related healthcare setting.
• Knowledge of medical terminology, clinical documentation, diagnostic testing, treatment planning, and healthcare reimbursement processes.
• Strong understanding of medical necessity criteria and payer authorization requirements.

Responsibilities

• Partner with providers, clinic staff, and interdisciplinary teams to facilitate prior authorizations and support medical necessity requirements for assigned services and treatments.
• Reviews medical records and clinical documentation to ensure submissions meet payer requirements and support medical necessity review and determinations.
• Submits prior authorization, pre-certification, and medical necessity requests to commercial, Medicare, Medicaid, and other third-party payers.
• Researches and interprets payer policies, coverage guidelines, and authorization requirements to facilitate timely approval of services.
• Monitors authorization requests, tracks outcomes, and proactively follows up on pending, delayed, or incomplete determinations.
• Collaborates with providers and clinical staff to obtain additional documentation required to support authorization requests, reconsiderations, and appeals.
• Reviews authorization denials, identifies opportunities for appeal, and coordinates the submission of supporting clinical documentation for reconsideration.
• Communicates authorization status, payer requirements, approvals, and denial outcomes to providers, clinic staff, and other stakeholders in a timely manner.
• Accurately documents authorization activities, payer communications, determinations, and appeal outcomes within the electronic health record and applicable tracking systems.
• Serves as a clinical resource regarding payer regulations, medical necessity criteria, authorization processes, and denial management while supporting quality improvement initiatives and regulatory compliance.

Skills

RN license

Communication skills

Organization

Education

Associate Degree in Nursing

Bachelor of Science in Nursing preferred

Tools

Microsoft Office

Job description

Join Our Logan Health Team as a Clinical Authorization Specialist!

Our Mission : Quality, compassionate care for all.

Our Vision : Reimagine health care through connection, service and innovation.

Our Core Values : Be Kind | Trust and Be Trusted | Work Together | Strive for Excellence.

Logan Health is looking for an experienced RN to take on the role of Clinical Authorization Specialist!

What you'll do

You’ll partner with clinic leadership, providers, nursing staff, and other interdisciplinary team members to support medical necessity reviews, prior authorization requests, and payer denial management for assigned services and treatments. Utilizing clinical expertise, this position evaluates documentation, identifies authorization requirements, facilitates appeals, and collaborates with payers to obtain coverage approvals while minimizing delays in patient care. The position serves as a resource regarding payer guidelines and medical necessity criteria, ensuring accurate documentation, timely communication of authorization outcomes, and supporting optimal patient access to care.

Location

This unique hybrid position will work approximately four days remotely and one day on site at Logan Health Medical Center in Kalispell, MT.

Applicants must reside in the Flathead Valley area as you will be meeting weekly on site with clinical staff, UM Specialists, and providers on initiatives and provide education.

Qualifications

• Current Montana RN license or multistate compact license with authorization to practice nursing in Montana.
• Associate Degree in Nursing required; Bachelor of Science in Nursing preferred.
• Minimum three (3) years of clinical nursing experience in acute care, ambulatory, specialty clinic, infusion, oncology, case management, utilization management, care coordination, or a related healthcare setting.
• Knowledge of medical terminology, clinical documentation, diagnostic testing, treatment planning, and healthcare reimbursement processes.
• Strong understanding of medical necessity criteria and payer authorization requirements.
• Promotes excellence through setting high standards and providing high quality outcomes.
• Ability to act with integrity, kindness, and exhibit empathy.
• Excellent organizational skills, detail-oriented, a self-starter, possess critical thinking skills and be able to set priorities and function as part of a team as well as independently.
• Commitment to working in a team environment and maintaining confidentiality as needed.
• Excellent verbal and written communication skills including the ability to communicate effectively with various audiences.
• Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.
• Possess and maintain computer skills to include working knowledge of Microsoft Office Suite and ability to learn other software as needed.

Job Specific Duties

• Partners with providers, clinic staff, and interdisciplinary teams to facilitate prior authorizations and support medical necessity requirements for assigned services and treatments.
• Reviews medical records and clinical documentation to ensure submissions meet payer requirements and support medical necessity review and determinations.
• Submits prior authorization, pre-certification, and medical necessity requests to commercial, Medicare, Medicaid, and other third-party payers.
• Researches and interprets payer policies, coverage guidelines, and authorization requirements to facilitate timely approval of services.
• Monitors authorization requests, tracks outcomes, and proactively follows up on pending, delayed, or incomplete determinations.
• Collaborates with providers and clinical staff to obtain additional documentation required to support authorization requests, reconsiderations, and appeals.
• Reviews authorization denials, identifies opportunities for appeal, and coordinates the submission of supporting clinical documentation for reconsideration.
• Communicates authorization status, payer requirements, approvals, and denial outcomes to providers, clinic staff, and other stakeholders in a timely manner.
• Accurately documents authorization activities, payer communications, determinations, and appeal outcomes within the electronic health record and applicable tracking systems.
• Serves as a clinical resource regarding payer regulations, medical necessity criteria, authorization processes, and denial management while supporting quality improvement initiatives and regulatory compliance.
• The above essential functions are representative of major duties of positions in this job classification. Specific duties and responsibilities may vary based upon departmental needs. Other duties may be assigned similar to the above consistent with knowledge, skills and abilities required for the job. Not all of the duti