Prior Authorization Nurse

Children's of Alabama; Birmingham (AL); On-site; USD 85,000 - 105,000; Full time

Job summary

Children’s of Alabama in Birmingham (Main Campus, Lee Building) seeks a PA Nurse in Clinical Documentation Integrity. The role handles infusion prior authorizations, works with providers and Billing, and supports documentation quality to ensure timely patient care and reimbursement.

Schedule is 8-4:30, Monday-Friday, Day Shift. Requires RN license in Alabama, BSN/ADN, 5+ years nursing, 1 year infusion PA exp preferred. Collaborative, organized team player essential.

Qualifications

• RN with Alabama licensure required.
• Minimum 5 years nursing experience; 1 year prior authorization experience preferred.
• BSN or ADN from an accredited nursing program.

Responsibilities

• Obtain outpatient infusion prior authorizations across the organization.
• Collaborate with providers to provide necessary documentation and peer-to-peer support when needed.
• Coordinate with Billing on denials and appeals to support patient care and reimbursement.
• Educate physicians and clinical staff on documentation requirements and processes.

Skills

Nursing

Prior Authorization

Infusion therapies

Documentation accuracy

Customer service

Education

BSN or ADN from accredited program

RN licensure in Alabama

Associate of Science in Nursing

Job description

In Clinical Documentation Integrity at Main Campus Lee Building

Work schedule will be Full-time on the Day Shift, 8-4:30.

Summary:
Performs a variety of duties related to obtaining prior authorization required by insurance companies for outpatient infusions. The Prior Authorization (PA) Nurse will be responsible for ensuring all infusion prior authorizations are completed across the organization, as well as, facilitating procedure-related prior authorizations that have escalated to a peer-to-peer or clinical appeal level. The PA Nurse will be responsible for providing the necessary supporting documentation in collaboration with a group of diverse health care providers. This individual must have strong organization skills, attention to detail and customer service skills. This individual will be expected to satisfy internal and external customer’s perceived needs.

Other information:

Education

• BSN of ADN from an accredited school of nursing and current licensure as a registered professional nurse in the State of Alabama required.

Experience

• Minimum 5 years of nursing experience. Minimum of 1 year of medication prior authorization experience preferred.

Credentials with Equivalent Qualifications

Essential

• Registered Nurse AL Single State or any of the following equivalent qualifications below:
• Registered Nurse AL NLC Multi State
• Registered Nurse Non-AL NLC Multi State

Education with Equivalent Qualifications

Essential

• Associate of Science Nursing in Nursing

The Clinical Documentation Integrity (CDI) department plays a key role within the Revenue Cycle by ensuring the accuracy and integrity of clinical documentation and related processes. The department encompasses several specialized areas: Inpatient and Outpatient CDI, Infusion Prior Authorizations, Medical Audit, and Medicaid Screening. Each area is staffed by experienced nurses who review medical records for various clinical and regulatory purposes. Inpatient and Outpatient CDI Nurses conduct concurrent and retrospective reviews of medical records to ensure documentation accurately reflects the patient’s clinical status, severity of illness, and treatments. Their work supports appropriate coding, reimbursement, and compliance, while also providing ongoing documentation education to physicians and clinical staff. Infusion Prior Authorization Nurses manage prior authorization requests for outpatient infusions, including those requiring peer-to-peer reviews or appeals. They collaborate closely with Billing on denials and appeals to support timely patient care and reimbursement. Medical Audit Nurses perform chart audits to ensure hospital charges are appropriate and compliant. They identify billing trends, correct discrepancies, and support hospital departments with charge integrity. Medicaid Screening Nurses focus on EPSDT and Interperiodic Screenings for patients with Medicaid coverage. Their detailed reviews ensure compliance with state and federal Medicaid regulations. Together, these teams support clinical excellence, regulatory compliance, and financial sustainability through comprehensive documentation and review processes.

Schedule: 8-4:30, Day Shift, Monday-Friday Standard Days