Authorization Nurse RN

Job Description

Evaluate authorization requests and authorize, modify or pend per appropriate criteria. Refer authorization requests not meeting criteria to specialty physician reviewer according to established medical necessity, benefit and eligibility criteria to assure appropriate, efficient and timely medical care.

• Review and process urgent and non-urgent authorization requests (via phone, fax, and electronic submission) for medical necessity according to established criteria and authorize, pend or modify as appropriate.
• Obtain additional medical information as necessary from requesting provider.
• Communicate with providers and members regarding status of authorization requests.
• Assist interdepartmental staff members to resolve issues related to the authorization process.
• Refer information regarding members to other departments as appropriate for follow-up (e.g., Case Management, Health Education, TPL, COB).
• Process authorization requests (routine, urgent and retrospective) according to department performance standards.
• Support Medical Management team authorizations, clinical initiatives, provider education, and other special projects as assigned.
• Utilize a variety of medical necessity, contractual and benefit criteria to determine appropriate authorization decisions.
• Collaborate with Medical Directors and other designated physician leaders for making clinical decisions.
• Participate in on‑call or alternate work hour programs as needed to meet regulatory compliance requirements.
• Perform other duties as assigned by supervisor/manager.

• Minimum three years clinical nursing experience.
• Utilization Management experience preferred.
• Excellent verbal and written communication skills.
• Ability to work effectively with a variety of customers including physicians, office staff, and members.
• Ability to work independently with self‑initiative and discipline.
• Working knowledge of personal computers.
• Managed care experience and certification preferred.
• Knowledge of ICD‑10 and CPT coding.
• Excellent organizational skills with ability to meet expected and unexpected time frames.

Active, unrestricted California licensure:
Registered (RN) or Licensed Vocational Nurse (LVN).

Annual Salary Range $110,000 to $

Hill Physicians is an Equal Opportunity Employer.