Prior Authorization RN Reviewer

Medasource; Phoenix (AZ); On-site; USD 75,000 - 95,000; Full time

Job summary

Medasource is seeking a Prior Authorization RN in Phoenix, AZ to review and process pre-service determinations and concurrent reviews. The role emphasizes adherence to evidence-based guidelines, regulatory standards, and efficient documentation to support cost-effective patient care.

Responsibilities include collaboration with providers and plan stakeholders, ensuring accurate data transfer, and escalation to Medical Directors when guidelines are not clearly met; familiarity with MCG, InterQual,

Qualifications

• Active RN license required in AZ or compact state.
• Outpatient prior authorization for surgeries and DME focus.
• Medicare review experience preferred.
• Experience with guidelines review.
• Familiarity with MCG criteria, CareWebQI and InterQual.

Responsibilities

• Review and process prior authorization requests.
• Collaborate with internal and external stakeholders.
• Transfer patient information for pre-service determinations and care transitions.
• Assess medical necessity and optimize plan outcomes.
• Educate stakeholders on population health management and evidence-based practices.
• Refer requests to Medical Director when guidelines are not met.
• Understand plan documents and authorization criteria.
• Participate in holiday call rotations.

Skills

RN license

AZ license/compact

Outpatient prior auth

Medicare experience

MCG criteria

CareWebQI/InterQual

Guidelines review

Tools

CareWebQI

InterQual

Job description

POSITION SUMMARY:

The Prior Authorization RN is responsible for reviewing and processing medical prior authorization requests to ensure services are medically necessary, meet evidence-based guidelines, and align with the health plan’s policies. This RN plays a critical role in supporting cost-effective care while ensuring quality and compliance in alignment with regulatory and accreditation standards.

CORE FUNCTIONS

1. Manages health Plan consumer/beneficiaries across the health care continuum to achieve optimal clinical, financial, operational, and satisfaction outcomes.

2. Provides pre-service determinations, concurrent review, and case management functions within Medical Management. Ensures quality of service and consistent documentation.

3. Works collaboratively with both internal and external customers in assisting health Plan consumers/beneficiaries and providers with issues related to prior authorization, utilization management, and/or case management. Meets internal and external customer service expectations regarding duties and professionalism.

4. Performs transfer of accurate, pertinent patient information to support the pre-service determination(s), the transition of patient care needs through the continuum of care, and performs follow-up calls for advanced care coordination. Documents accurately and timely, all interventions and necessary patient-related activities in the correct medical record.

5. Evaluates the medical necessity and appropriateness of care, optimizing health Plan consumer/beneficiary outcomes. Identifies issues that may delay patient services and refers to case management, when indicated, to facilitate resolution of these issues, pre-service, concurrently, and post-service.

6. Provides ongoing education to internal and external stakeholders who play a critical role in the continuum of care model. Training topics consist of population health management, evidence-based practices, and all other topics that impact medical management functions.

7. Identifies and refers requests for services to the appropriate Medical Director and/or other physician clinical peer when guidelines are not clearly met. Conducts call rotation for the health plan, as well as departmental call rotation for holidays.

8. Maintains a thorough understanding of each plan, including the Evidence of Coverage, Summary Plan Description, authorization requirements, and all applicable federal, state, and commercial criteria, such as CMS, MCG, and Hayes.

Minimum Qualifications:

• Active RN license -- AZ License or Compact State License
• Focus on Outpatient Prior Auths for surgeries and DME (Durable Medical Equipment)
• Medicare review experience is highly preferred
• Experience with reviewing guidelines (this position is more pre-service)
• Experience with MCG criteria, CareWebQI & Interqual