RC Pre-Authorization Clinician - Remote

Conifer Health Solutions; Frisco (TX); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare company is seeking a Remote RC Pre-Authorization Clinician to oversee clinical pre-authorization activities. The role involves coordinating with physicians for payment authorizations and ensuring compliance with payer criteria. Ideal candidates will possess a valid nursing license and have experience in pre-authorization or utilization review.

Qualifications

• 3-5 years of experience in pre-authorization or utilization review.
• Current RN/LPN licensure; certifications such as CPUR, CPUM, CPHM, or CCM preferred.

Responsibilities

• Perform pre-service authorization reviews to obtain payment authorization.
• Engage with internal and external customers to prevent future disputes.
• Support quality management system through audits and feedback.

Skills

Critical thinking

Problem-solving

Decision-making

Excellent written and verbal customer service

Conflict resolution

Education

Valid nursing license (RN or LPN preferred)

Tools

Microsoft Office (Excel and Word)

Job description

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Job Summary

The Revenue Cycle Management Clinician for the Pre-Authorization Solution is responsible for:

• All clinical pre-authorization activities associated with patients financially cleared through the Patient Access Support Unit (PASU) and/or the Center for Patient Access Services (CPAS).
• Coordinating with ordering physicians and/or facility staff to secure the necessary prior payment authorization utilizing applicable payer criteria.

Essential Duties And Responsibilities

• Performs pre-service authorization reviews to obtain payment authorization for both inpatient and outpatient services. Abstracts clinical information to support pre-authorization using recognized criteria; communicates the clinical information supporting medical necessity and documents the outcome.
• Supports the organization’s quality management system through participation in audits and department projects, providing feedback for workflow and procedure improvements.
• Demonstrates proficiency in using multiple electronic tools required by Conifer and its clients.
• Engages with internal and external customers to prevent future disputes, identifies process gaps, and recommends solutions to leadership.
• Other duties as assigned.

Knowledge, Skills, Abilities

• Ability to work independently and meet deadlines.
• Proficiency in applying payer authorization criteria.
• Excellent written and verbal customer service skills.
• Intermediate proficiency in Microsoft Office (Excel and Word).
• Critical thinking, problem-solving, and decision-making skills.
• Professional interaction with clinical and non-clinical partners.
• Ability to prioritize tasks efficiently.
• Conflict resolution skills and effective communication at all levels.
• Ability to research payer guidelines and regulatory processes.

Qualifications

• Valid nursing license (RN or LPN preferred).
• 3-5 years of experience in pre-authorization or utilization review, preferably in medical-surgical or critical care settings.
• Current RN/LPN licensure; certifications such as CPUR, CPUM, CPHM, or CCM are preferred.