prior authorization nurse

Ann & Robert H. Lurie Children's Hospital of Chicago

<div><div>Ann &amp; Robert H. Lurie Children&rsquo;s Hospital of Chicago provides superior pediatric care in a setting that offers the latest benefits and innovations in medical technology, research and family-friendly design. As the largest pediatric provider in the region with a 140-year legacy of excellence, kids and their families are at the center of all we do. Ann &amp; Robert H. Lurie Children&rsquo;s Hospital of Chicago is ranked in all 10 specialties by the U.S. News &amp; World Report.</div><div></div><div><div><div><div><div><div><div><div>
Location</div></div></div></div></div></div></div></div>
680 Lake Shore Drive<div></div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div><div>
Job Description</div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div><div>
This is a remote position that requires mandatory travel to the Lurie Main Hospital campus once per month.</div><div>
Must work 8 hours per day with a flexed start time available.</div><div></div><div>
Must have an Illinois RN license and 3 years of practice experience in Peds, Ambulatory, or Prior Authorization to receive an interview.</div><div>
Experience using EPIC electronic medical record preferred.</div><div></div><div>
General Summary:</div><div>
The Prior Authorization Nurse Coordinator coordinates the activities which pertain to the Prior Authorization Department. The Nurse Coordinator is responsible for ensuring all in-scope medication prior authorizations are completed across the organization as well as facilitating imaging related pre-certifications that have escalated to a peer-to-peer or clinical appeal level. The Nurse Coordinator is responsible for providing the necessary supporting documentation in collaboration with a group of diverse health care providers.</div><div></div><div>
Essential Job Functions:</div><ul><li><div>
Coordinate the activities which pertain to the Clinical Prior Authorization Department.</div></li><li><div>
Obtain medication prior authorizations from insurance entities utilizing Covermymeds in accordance with standard written procedures, guidelines, and state and federal regulations while also, maintaining compliance to medical record confidentiality regulations.</div></li><li><div>
In coordination with the Financial Clearance team, this RN will manage peer to peer escalation cases for pre-certification and appeals for imaging denials.</div></li><li><div>
Manage correspondence with insurance entities, physicians, specialists, and patients as required and ensuring all necessary supporting documentation is provided for approvals.</div></li><li><div>
Manage denials and submit appeals, ensuring all necessary supporting documentation is provided to get them approved from insurance entities.</div></li><li><div>
Create accurate and consistent documentation in patient&rsquo;s records to ensure that prior authorization information is properly updated. Record all prior authorization phone calls, documents and authorization numbers in EPIC utilizing the patient chart and referral module.</div></li><li><div>
Utilize the patient medical record to submit supporting clinical records and/or providing verbal medical necessity validation and support for pending pre-certifications.</div></li><li><div>
Manage physical medical records and utilization management documentation from insurance entities to support approval of pre-certifications.</div></li><li><div>
Self-driven and motivated to work independently for the purpose of utilizing resources to expand knowledge base on drug information and basic pathophysiology.</div></li><li><div>
Acts as a resource to hospital personnel with regard to the care and coordination of medication prior authorizations as well as pre-certifications and troubleshooting pharmacy end issues as it relates to confirming the pharmacy is able to obtain paid claims.</div></li><li><div>
Other job functions as assigned.</div></li></ul><div></div><div>
Knowledge, Skills and Abilities:</div><ul><li><div>
A BSN degree from an accredited school of nursing and current licensure as a registered professional nurse in the State of Illinois required. Master's prepared preferred.</div></li><li><div>
Three years of relevant nursing experience. With a minimum of 1 year of medication prior authorization and/or pre-certification experience preferred.</div></li><li><div>
Experience working in partnership with health care professionals and support staff in an office setting is necessary.</div></li><li><div>
Must demonstrate the ability to problem solve and support teamwork in a multidisciplinary setting in a positive and professional manner. The candidate must demonstrate excellent written and verbal communication skills.</div></li><li><div>
Knowledge of online authorization systems and status review and ability to track in-process authorizations from multiple sources. Computer skills required. Proficient in Microsoft Office applications preferred.</div></li></ul><div></div><div>
Education</div>
Bachelor's Degree: Nursing (Required)<div></div><div>
Pay Range</div>
$83,200.00-$137,280.00 Salary<div></div><div>
At Lurie Children&rsquo;s, we are committed to competitive and fair compensation aligned with market rates and internal equity, reflecting individual contributions, experience, and expertise. The pay range for this job indicates minimum and maximum targets for the position. Ranges are regularly reviewed to stay aligned with market conditions. In addition to base salary, Lurie Children&rsquo;s offer a comprehensive rewards package that may include differentials for some hourly employees, leadership incentives for select roles, health and retirement benefits, and wellbeing programs. For more details on other compensation, consult your recruiter or click the following <div>link</div> to learn more about our benefits.</div><div></div><div>
Benefit Statement</div><div></div><div>
For full time and part time employees who work 20 or more hours per week we offer a generous benefits package that includes:</div><div>
Medical, dental and vision insurance</div><div>
Employer paid group term life and disability</div><div>
Employer contribution toward Health Savings Account</div><div>
Flexible Spending Accounts</div><div>
Paid Time Off (PTO), Paid Holidays and Paid Parental Leave</div><div>
403(b) with a 5% employer match</div><div></div><div>
Various voluntary benefits:</div><ul><li><div>
Supplemental Life, AD&amp;D and Disability</div></li><li><div>
Critical Illness, Accident and Hospital Indemnity coverage</div></li><li><div>
Tuition assistance</div></li><li><div>
Student loan servicing and support</div></li><li><div>
Adoption benefits</div></li><li><div>
Backup Childcare and Eldercare</div></li><li><div>
Employee Assistance Program, and other specialized behavioral health services and resources for employees and family members</div></li><li><div>
Discount on services at Lurie Children&rsquo;s facilities</div></li><li><div>
Discount purchasing program</div></li></ul><div></div><div>
There&rsquo;s a Place for You with Us</div><div></div><div>
At Lurie Children&rsquo;s, we embrace and celebrate building a team with a variety of backgrounds, skills, and viewpoints &mdash; recognizing that different life experiences strengthen our workplace and the care we provide to the Chicago community and beyond. We treat everyone fairly, appreciate differences, and make meaningful connections that foster belonging. This is a place where you can be your best, so we can give our best to the patients and families who trust us with their care.</div><div></div><div><i><br>
Lurie Children&rsquo;s and its affiliates are equal employment opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity or expression, religion, national origin, ancestry, age, disability, marital status, pregnancy, protected veteran status, order of protection status, protected genetic information, or any other characteristic protected by law.</i></div><div>
Support email: <div>peoplequestions@luriechildrens.org</div></div></div>

Prior Authorization Nurse Coordinator

UpScriptHealth

<p><b>Company Description: </b></p><p>At UpScript Health, we believe patients deserve access to medications through experiences that work for them. Our proprietary, best-in-class technology allows patients to participate in personal health screenings, consult with physicians or nurse practitioners, utilize insurance benefits for medications when appropriate, and receive home delivery of medications. All of this is done in an easy, quick, and discrete process.</p><p>This is a chance to work in a great environment and be a part of a progressive organization dedicated to the well-being of our patients and team members and a leader in the field of telehealth and patient care.</p><p><b>Job Overview:</b></p><p>We are seeking a highly skilled and detail-oriented Prior Authorization &amp; Referral Management Specialist to join our dynamic tele-healthcare team. This individual will play a critical role in managing the prior authorization process, referral coordination, and insurance-related communications. The ideal candidate will have experience working with prior authorization systems, collaborating with insurance providers, and coordinating care for patients, ensuring that all medication and treatment plans are aligned with insurance requirements.</p><p><b>Key Responsibilities:</b></p><ul><li>Submit and manage prior authorization requests through <b>CoverMyMeds</b> and payer portals</li><li>Document all activity accurately and thoroughly in <b>Salesforce</b></li><li>Monitor PA status and proactively follow up with insurance companies</li><li>Communicate with patients both verbally and in writing to explain prior authorization processes, answer questions, etc.</li><li>Coordinate with pharmacies to resolve claim rejections</li><li>Track denials and prepare appeals as needed</li><li>Maintain compliance with HIPAA and all regulatory requirements</li><li>Identify workflow improvements to increase efficiency and approval rates</li><li>Collaborate with teammates to ensure timely and accurate completion of tasks.</li></ul><p><b>Qualifications:</b></p><p>● Minimum of 2 years of patient support experience in the healthcare industry.</p><p>● Proven experience with prior authorization systems (Cover My Meds, PromptPA, SureScripts, etc.).</p><p>● Strong understanding of insurance benefit investigations, prior authorization processes, and status follow-up.</p><p>● Previous experience in a healthcare setting, with a solid understanding of HIPAA, medical records, documentation, and healthcare terminology.</p><p>● Proficiency in EMR systems (e.g., Athena, Salesforce) and experience working with multiple healthcare software platforms.</p><p>● Comfortability with Google Workspace (Drive, Sheets, Docs, Help Center, Email), Slack, and other web-based tools for communication and record-keeping.</p><p>● Experience with a multi-phone system, handling both incoming and outgoing calls effectively.</p><p>● Ability to communicate with patients clearly, empathetically, and professionally, both verbally and in writing.</p><p>● Excellence in documenting medical records, ensuring clarity, accuracy, and compliance.</p><p>● Ability to work collaboratively with teammates, communicating effectively to meet patient and team needs.</p><p>● Strong organizational skills with the ability to prioritize and manage multiple tasks.</p><p>● Willingness to ask for help when needed to ensure tasks are completed effectively and efficiently.</p><p><b>Preferred Skills:</b></p><p>● Experience in a fast-paced, high-volume healthcare environment.</p><p>● Familiarity with insurance policies, billing codes, and healthcare compliance.</p><p>● Self-directed with an ability to manage competing priorities while maintaining a focus on patient care and service.</p><p><b>Why Join Us:</b></p><p>● Opportunity to work with a collaborative and compassionate team.</p><p>● Competitive salary and benefits.</p><p>● Professional growth and development opportunities.</p><p>● Flexible working arrangements in a supportive work environment.</p><p>● Paid vacation, sick time</p><p>● Company supported health, dental, vision and life insurance</p><p>● 401k with 4% company match after 6 months</p><p>Job Type: Full-time</p><p>Pay: $21.00 - $22.00 per hour</p><p>Benefits:</p><ul><li>401(k) matching</li><li>Dental insurance</li><li>Health insurance</li><li>Life insurance</li><li>Paid time off</li><li>Vision insurance</li></ul><p>Location:</p><ul><li>Remote (Required)</li></ul><p>Work Location: Remote</p>

Prior Authorization Specialist

Urology Centers of Alabama

<div><p><b>General Summary</b></p><p>
The Prior Authorization Specialist coordinates and secures insurance authorization for medications, in-office injections, and imaging when needed to support timely patient care. This role involves reviewing payer requirements, gathering appropriate clinical documentation, and communicating with insurance companies, pharmacies, and internal staff to facilitate authorization approvals. The ideal candidate demonstrates strong time management, attention to detail, integrity, and the ability to manage multiple requests while maintaining organization and professionalism in a high-volume environment.
</p><p></p><p><b>Key Responsibilities
</b></p><ul><li><p>Complete authorization submissions through electronic platforms, payer portals, and telephone communications with insurance representatives when required.
</p></li><li><p>Review patient charts to obtain relevant clinical documentation needed to support authorization requests
</p></li><li><p>Communicate professionally with insurance companies, pharmacies, patients, and internal staff regarding authorization requirements and status updates.
</p></li><li><p>Track and update prior authorization requests and outcomes using internal tracking tools and insurance portals to ensure timely processing and follow-up.
</p></li><li><p>Demonstrate accountability for assigned authorization requests by monitoring status and following up with payers when necessary.
</p></li><li><p>Actively monitor PA Pool and EHR inbox communications to ensure timely response to authorization requests and related inquiries.
</p></li><li><p>Ensure all prior authorization submissions and supporting documentation accurately reflect the patient&rsquo;s medical record and comply with payer requirements.
</p></li></ul><p><b>Physical Demands</b></p><p>
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.</p><p>
</p><p>While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; stoop, kneel, crouch, or crawl; and talk or hear. The employee must occasionally lift and/or move more than 45 pounds.
</p><ul><li><p>Familiarity with medical terminology and working knowledge of medical coding systems (CPT, ICD-10) relevant to prior authorization requests.
</p></li><li><p>Strong organizational and time management skills, with the ability to prioritize urgent requests and meet deadlines in a high-volume environment.
</p></li><li><p>Excellent written and verbal communication skills when interacting with patients, insurance representatives, pharmacies, and internal clinical staff.
</p></li><li><p>Ability to work both independently and collaboratively within a team while managing multiple tasks simultaneously.
</p></li></ul><ul><li><p>Demonstrates integrity, professionalism, and ethical decision-making when handling patient information and submitting prior authorization requests.
</p></li><li><p>HS Diploma or GED required.</p></li></ul></div>

Prior Authorization

Humana

<div>
 <strong>
  Become a part of our caring community and help us put health first
  <br/>
  <br/>
 </strong>
 Are you a transitioning military service member or a military spouse looking for an internship that supports the goal to put health first?
 <br/>
 <br/>
 The DOW SkillBridge Internship and Military Spouse Fellowship Programs will provide you with key training to perform your internship. You will partner with your team to support members, projects, and to meet goals impacting business outcomes. The professionals you work with at Humana will depend on the type of internship you select. They may include healthcare professionals, HR, and IT, to name a few. The objective is to support and facilitate care for members.
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 <br/>
 To be eligible for this internship, you must either be a transitioning military service member or a military spouse, and you must obtain eligibility to participate in these DOW sponsored programs.
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 The Prior Authorization, Registered Nurse, RN, Intern will report to a manager of the National Medicaid team. You will utilize training and engage formerly acquired skillsets to complete medical necessity reviews for requested services using clinical judgment and provides referrals to internal stakeholders for further review depending on case findings.
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  You will participate in the following assignments in this role:
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  Clinical Review
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   Conduct comprehensive clinical reviews of prior authorization requests to determine medical necessity and benefit eligibility.
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   Apply advanced evidence-based clinical guidelines in review decisions.
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   Ensure compliance with accreditation, state, and federal regulations.
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  Communication And Coordination
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   Communicate with healthcare providers to obtain necessary clinical information and clarify requests.
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   Coordinate with medical directors and interdisciplinary teams to support decision-making.
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   Serve as a liaison between clinicians, internal departments, and members.
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  Documentation And Reporting
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   Document all review findings and decisions in clinical documentation systems.
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   Ensure timely and accurate documentation of prior authorization determinations.
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   Support reporting initiatives and provide data for performance improvement projects.
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  Quality Assurance
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   Implement quality assurance measures to ensure accuracy and consistency in prior authorization decisions.
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   Conduct regular audits and reviews to maintain high standards of service.
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   Identify process improvement opportunities and contribute to performance improvement projects.
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  </li>
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  Education And Training
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   Educate providers and staff on prior authorization policies, criteria, and review processes.
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   Provide mentorship and feedback to nonclinical staff and peers to enhance workflow efficiency.
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   Stay current with clinical best practices and regulatory changes.
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  </li>
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  Required Qualifications
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  Use your skills to make an impact
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   You must be a transitioning service member eligible to participate in the DOW SkillBridge or a military spouse eligible to participate in the military spouse fellowship&middot;
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   Active Registered Nurse, RN, enhanced Compact, (eNLC) license without restrictions or disciplinary action.
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   Minimum two (2) years clinical nursing experience such as acute care, emergency room, ICU, skilled or rehabilitation setting.
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  <li>
   Working knowledge of MS Office including Word, Excel, PowerPoint, and Teams in a Windows based environment and an ability to quickly learn new systems and ability to troubleshoot and resolve basic technical difficulties in a remote environment.
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   Possess an interest in working in the managed care industry
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  Preferred Qualifications
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  <li>
   Bachelor's degree
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   Previous Medicare/Medicaid experience.
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   Previous experience in prior authorization, utilization management.
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   Experience working with MCG or Interqual guidelines.
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   Certification in Case Management, (CCM) or Utilization Review, (UR).
  </li>
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   Knowledge of payer policies, insurance companies and government health programs.
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  </li>
 </ul>
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  Workstyle:
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 Remote Work at Home
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  Location:
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 Must reside in a state that participates in the enhanced compact license, (eNLC)
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  Work Schedule:
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 Weekdays 8:00 AM to 4:30 PM Central Time
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  Travel:
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 None
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  Additional Information
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  Work At Home Requirements
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   WAH requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
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   A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
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   Satellite and Wireless Internet service is NOT allowed for this role.
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   A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
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  </li>
 </ul>
 <strong>
  The DOW SkillBridge Internship Program
 </strong>
 provides transitioning military service members time to gain civilian work experience while still on active duty with an employer for a period approved by their command and the DOW, with an average timeline of 90 days.
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 <strong>
  The Military Spouse Fellowship Program
 </strong>
 connects military spouses with employers offering a variety of professional onsite, field, or remote based opportunities for a period up to 12 weeks.
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   Networking opportunities will be provided while participating in the Internship or Fellowship.
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   Due to factors such as location, and/or requirements that cannot be modified, full-time employment is not guaranteed upon completion of the Internship or Fellowship.
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 </ul>
 <strong>
  Interview Format
 </strong>
 As part of our hiring process, we will be using a screening and interviewing technology provided by HireVue, a third-party vendor. This technology provides our team of recruiters and hiring leaders with an enhanced method for decision-making. If you are selected to move forward from your application prescreen, you will receive an email correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview.
 <strong>
  (please be sure to check your spam or junk folders often to ensure communication isn't missed)
 </strong>
 If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes. If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
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 Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
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    Scheduled Weekly Hours
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 1
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 <strong>
  About Us
  <br/>
  <br/>
 </strong>
 Humana Inc. (NYSE: HUM) is committed to putting health first &ndash; for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health &ndash; delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
 <br/>
 <br/>
 <strong>
  Equal Opportunity Employer
  <br/>
  <br/>
 </strong>
 It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
</div>


Preauthorization Registered Nurse

Molina Healthcare

JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.
<br><br>
Essential Job Duties
<br><br>
<ul>
<li>Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.</li>
<li>Analyzes clinical service requests from members or providers against evidence based clinical guidelines.</li>
<li>Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.</li>
<li>Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.</li>
<li>Processes requests within required timelines.</li>
<li>Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.</li>
<li>Requests additional information from members or providers as needed.</li>
<li>Makes appropriate referrals to other clinical programs.</li>
<li>Collaborates with multidisciplinary teams to promote the Molina care model.</li>
<li>Adheres to utilization management (UM) policies and procedures.</li>
</ul>
Required Qualifications
<br><br>
<ul>
<li>At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.</li>
<li>Registered Nurse (RN). License must be active and unrestricted in state of practice.</li>
<li>Ability to prioritize and manage multiple deadlines.</li>
<li>Excellent organizational, problem-solving and critical-thinking skills.</li>
<li>Strong written and verbal communication skills.</li>
<li>Microsoft Office suite/applicable software program(s) proficiency.</li>
</ul>
Preferred Qualifications
<br><br>
<ul>
<li>Certified Professional in Healthcare Management (CPHM).</li>
<li>Recent hospital experience in an intensive care unit (ICU) or emergency room.</li>
</ul>
<b>To all current Molina employees:</b> If you are interested in applying for this position, please apply through the Internal Job Board.
<br><br>
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
<br><b>Pay Range:</b> $23.76 - $51.49 / HOURLY
<br><ul>
<li>Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.</li>
</ul>


Care Review Clinician (RN)

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