Prior Authorization RN — Utilization & Care Continuity Lead

Arizona Priority Care; Chandler (AZ); Hybrid; USD 114,616,320 - 120,347,136; Full time

Benefits offered by this job

In-office role for 60 days

Hybrid schedule after training

Job summary

Arizona Priority Care is seeking a Prior Authorization Registered Nurse (RN) to conduct initial clinical reviews of preservice authorization requests, ensuring medical necessity and continuity of care. You will collaborate with PA staff and Medical Directors, pre-screen requests, and prepare SBAR-compliant cases for review.

The role requires a valid AZ RN license and a minimum of 3 years acute care or care management experience, with strong regulatory knowledge.

Qualifications

• Graduated from an accredited Registered Nurse Program.
• Current unrestricted AZ RN License.
• Minimum of 3 years acute care or care management experience.
• Knowledge of Medicare, state and local managed care regulations.
• Experience with record review and documentation standards.
• Proficient with Microsoft Office and EHR systems (NextGen, EzCap).

Responsibilities

• Monitor PA Nurse and Pharmacy Request queues for timely processing.
• Pre-screen authorization requests and gather missing information.
• Apply health plan criteria to assess medical necessity.
• Review PA Nursing requests per AZPC policies.
• Prepare SBAR-focused cases for Medical Directors.
• Compose medical necessity denial letters per CMS guidelines.
• Process at least 20 prior authorization requests daily.
• Maintain 98% accuracy in clinical reviews.
• Liaise between Medical Director and providers.
• Ensure HIPAA compliance and PHI privacy.
• Collaborate with Quality dept on reviews.
• Assist in member surveys analysis.
• Identify potential quality issues.
• Other duties as assigned.

Skills

Clinical Review

Care coordination

Regulatory knowledge

Communication

EHR proficiency (NextGen, EzCap)

Education

AZ RN License

Accredited RN Program

Tools

NextGen

EzCap

Microsoft Office Suite

Job description

Arizona Priority Care is seeking a Prior Authorization Registered Nurse (RN) to conduct initial clinical reviews of preservice authorization requests, ensuring medical necessity and continuity of care. You will collaborate with PA staff and Medical Directors, pre-screen requests, and prepare SBAR-compliant cases for review.

The role requires a valid AZ RN license and a minimum of 3 years acute care or care management experience, with strong regulatory knowledge.