Prior Authorization Nurse - 241209

Medix™; California; Hybrid; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a dedicated Prior Authorization Nurse to join their team. This role involves reviewing medical service referrals to assess necessity, utilizing your extensive medical knowledge and clinical guidelines. After an initial training period in Chatsworth, CA, the position will transition to a fully remote setup, allowing you to work from anywhere. With a Monday to Friday schedule, this is a fantastic opportunity for those with prior authorization experience looking to make a meaningful impact in healthcare.

Qualifications

• Must have current CA State licensure as a Licensed Vocational Nurse (LVN).
• At least 2 years of experience in a comparable position.

Responsibilities

• Review referrals for medical services to determine medical necessity.
• Develop clinical summaries for approval or denial recommendations.

Skills

Prior Authorization

Clinical Judgment

Medical Knowledge

Assessment Skills

Education

Licensed Vocational Nurse (LVN)

Job description

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Medix is hiring for a Prior Authorization Nurse for a Health Plan in CA. Must be able to train onsite in Chatsworth, CA. It will be fully remote after training is completed. The schedule is Monday - Friday 8:30 a.m. - 5:00 p.m. We are looking for someone with previous Prior Authorization experience.

Training: Chatsworth, CA (3-4 weeks)

Job Overview:

The UM Prior Authorization Nurse is responsible for reviewing referrals for medical services to determine medical necessity and course of action, using their independent judgment and extensive knowledge of medicine, along with clinical guidelines. The UM Prior Authorization Nurse confers with Nursing Manager, VP of Clinical Policy, and/or Medical Director as appropriate in utilization management or problem solving.

Reviews prior authorization referrals for medical necessity by:

• Exercising independent judgment and extensive knowledge of medicine.
• Independently reviewing and assessing records provided and determining how the patient specifically meets criteria for services being requested.
• Ensuring all health plans, state, and clinical guidelines are enforced in making decisions.
• Approval Recommendations: Developing clinical summaries for why a patient specifically meets criteria for services requested and independently making decisions to approve services.
• Denial Recommendations: Developing clinical summaries for why the information provided does not show the patient meeting criteria, and making recommendations for Medical Director’s review based on this assessment.

Qualifications/Experience:

• Current CA State licensure as a Licensed Vocational Nurse (LVN).
• At least 2 years of experience in a comparable position.
• Prior authorization or Managed Care experience preferred.