Prior Auth RN — Clinical Review & UM Specialist (Hybrid)

Arizona-Priority-Care; Chandler (AZ); On-site; USD 55,000 - 58,000; Full time

Job summary

Arizona Priority Care (AZPC) is a Chandler, AZ-based Integrated Provider Network focused on value-based care for Senior and Medicaid populations. The Prior Authorization Registered Nurse (RN) conducts initial clinical reviews, pre-screens requests, applies eligibility criteria, and prepares cases for UM review in collaboration with Medical Directors.

Responsibilities include handling queues, drafting denial letters that comply with CMS and policies, and maintaining 98% accuracy while processing

Qualifications

• Graduate from an accredited Registered Nurse program and hold an unrestricted AZ RN license.
• Minimum of 3 years acute care or care management experience.
• Knowledge of Medicare, state and local managed care regulations; prior managed care experience preferred.
• Strong understanding of Continuum of Care, care planning and transitions of care.

Responsibilities

• Monitor PA Nurse and Pharmacy Request queues and process routine/urgent prior authorizations in compliance with requirements.
• Pre-screen PA requests to ensure documentation is complete and obtain missing information as needed.
• Apply health plan criteria hierarchy to determine medical necessity for services.
• Conduct PA clinical reviews and approve requests when appropriate per AZPC policies.
• Prepare SBAR submissions for Medical Directors and ensure proper Utilization Management review hierarchy.
• Draft medical necessity denial letters meeting CMS and policy guidelines with clear language.
• Process at least 20 prior authorization requests daily, depending on complexity.
• Maintain a 98%+ clinical review accuracy rate and liaise with Medical Director and providers.
• Keep up-to-date with CMS, NCQA, and health plan regulations; report quality issues as needed.
• Ensure PHI privacy and engage with staff to deliver excellent customer service.

Skills

Attention to detail

Interpersonal communication

Verbal and written communication

Organizational skills

Project management

Team collaboration

Proficiency with MS Office

Education

Registered Nurse License (AZ)

Tools

NextGen

EzCap

Job description

Arizona Priority Care (AZPC) is a Chandler, AZ-based Integrated Provider Network focused on value-based care for Senior and Medicaid populations. The Prior Authorization Registered Nurse (RN) conducts initial clinical reviews, pre-screens requests, applies eligibility criteria, and prepares cases for UM review in collaboration with Medical Directors.

Responsibilities include handling queues, drafting denial letters that comply with CMS and policies, and maintaining 98% accuracy while processing