prior authorization nurse

Molina Healthcare

<div>
 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.
 
 
 
 Essential Job Duties
 
 
 
 <ul>
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 Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
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 Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
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 Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
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 Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
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 Processes requests within required timelines.
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 Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
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 Requests additional information from members or providers as needed.
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 Makes appropriate referrals to other clinical programs.
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 Collaborates with multidisciplinary teams to promote the Molina care model.
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 Adheres to utilization management (UM) policies and procedures.
 
 
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 Required Qualifications
 
 
 
 <ul>
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 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.
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 Registered Nurse (RN). License must be active and unrestricted in state of practice.
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 Ability to prioritize and manage multiple deadlines.
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 Excellent organizational, problem-solving and critical-thinking skills.
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 Strong written and verbal communication skills.
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 Microsoft Office suite/applicable software program(s) proficiency.
 
 
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 Preferred Qualifications
 
 
 
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 Certified Professional in Healthcare Management (CPHM).
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 Recent hospital experience in an intensive care unit (ICU) or emergency room.
 
 
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 To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
 
 
 Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
 
 
 Pay Range: $27.73 - $54.06 / HOURLY
 
 
 <ul>
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 Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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</div>

Care Review Clinician (RN)

Gainwell Technologies

<div>
 It takes great medical minds to create powerful solutions that solve some of healthcare&rsquo;s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you&rsquo;ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you&rsquo;ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You&rsquo;ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.
 
 
 
 Summary
 
 
 
 The Prior Authorization (PA) Pharmacist is responsible for reviewing prior authorization requests from providers to ensure safe and effective medication utilization. The PA Pharmacist will work with internal and external stakeholders to evaluate and continually develop strategies for Utilization Management.
 
 
 
 Essential Job Functions
 
 
 
 <ul>
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 Review prior authorization requests from medical professionals to ensure alignment with Preferred Drug List (PDL) criteria and current clinical guidelines.
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 Support peer-to-peer discussions with medical providers regarding prior authorization reviews.
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 Collaborate on the refinement of consultation scripting; solicit and utilize input from those contacted to improve scripting.
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 Contribute to the success of the Clinical Call Centers and Prior Authorization department by assisting with the implementation and management of both written and verbal communications to members and physicians. Serve as a resource for pharmacy-related questions and issues across the organization.
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 Contribute to program improvements by using continuous quality improvement processes, proactively identifying opportunities, and providing ongoing consultation and collaboration with product leaders.
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 Uphold the clinical integrity of pharmaceutical solutions by staying up to date on medication information and clinical guidelines, contributing to the identification of pharmacy program best practices, and collaborating with Medical Directors and Clinical Pharmacists to provide pharmacy expertise.
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 Collaborate internally with the pharmacy team (Pharmacy Manager, PDL Coordinator, Clinical Pharmacists) to identify trends or areas of opportunity, with the intent of identifying new drugs and therapeutic classes requiring utilization management.
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 Perform other duties as assigned.
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 Contribute creative solutions to improve the operational efficiency and effectiveness of the pharmacy team.
 
 
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 </ul>
 
 Requirements
 
 
 
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 PharmD or B.S. in Pharmacy with relevant specialty background.
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 Registered Pharmacist with an unrestricted state license (Connecticut Pharmacist License preferred but not required).
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 Minimum of four (4) years of experience in clinical pharmacy.
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 Strong verbal and written communication skills.
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 Highly proficient in Microsoft Office products and ability to quickly learn proprietary systems.
 
 
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 Basic Qualifications
 
 
 
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 Experience coordinating and collaborating with work teams preferred.
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 Ability to perform clinical reviews using relevant compendia and clinical trial data.
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 Managed care and/or prior authorization experience is a plus.
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 Strong research and implementation skills in practical settings.
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 Analytical skills that translate into practical and pragmatic recommendations.
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 Strong team orientation with respect for all members.
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 Strong interpersonal skills to support effective consultation and collaboration with internal and external stakeholders who do not directly report to this role.
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 Prior call center experience preferred.
 
 
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 Work Environment
 
 
 
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 Work from home; reliable high-speed internet connectivity is required.
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 Expected working hours: 9:00 AM to 5:00 PM Eastern Time, including select holidays and occasional weekend on-call coverage.
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 A dedicated, private workspace (HIPAA-compliant) with high-speed internet access is required.
 
 
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 Applications for this posting will be accepted until April 24, 2026.
 
 
 The pay range for this position is $90,900.00 - $129,900.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You&rsquo;ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
 
 
 We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You&rsquo;ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.
 
 
 
 Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines &ldquo;wages&rdquo; and &ldquo;wage rates&rdquo; to include &ldquo;all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
 
</div>

Prior Authorization Pharmacist - Connecticut Medicaid (Remote)

Veins OC

Job Overview We are seeking a proactive and detail-oriented Prior Authorization Specialist to join our healthcare team. In this vital role, you will be responsible for managing the authorization process for medical varicose vein clinic, ensuring timely approvals that facilitate seamless patient care. Your expertise in managed care policies, medical terminology, and insurance procedures will drive efficiency and accuracy in processing prior authorizations. This position offers an exciting opportunity to contribute to a dynamic healthcare environment where your skills directly impact patient outcomes and provider satisfaction.Responsibilities<ul><li>Review and evaluate prior authorization requests for varicose vein treatments, ensuring all documentation complies with insurance requirements and clinical guidelines</li><li>Communicate effectively with healthcare providers, insurance companies, and patients to gather necessary information and clarify authorization statuses</li><li>Verify insurance coverage, eligibility, and benefits using insurance verification tools and systems</li><li>Maintain detailed records of authorization requests, approvals, denials, and related correspondence in accordance with HIPAA regulations</li><li>Utilize CPT coding, ICD-9, ICD-10, and ICD coding standards to accurately document procedures and diagnoses for authorization purposes</li><li>Collaborate with medical office staff to facilitate smooth workflow and timely processing of authorizations</li><li>Stay updated on managed care policies, insurance plan changes, and coding updates to ensure compliance and accuracy</li></ul>Requirements<ul><li>Proven experience in managed care environments or medical office settings with a focus on prior authorizations</li><li>Strong knowledge of medical terminology, medical records management, and medical coding including CPT, ICD-9, ICD-10 codes</li><li>Familiarity with HIPAA regulations to ensure patient confidentiality and data security</li><li>Experience with insurance verification processes within healthcare VARICOSE VEIN TREATMENT AUTHORIZATONS SUCH AS ABLATION, VARITHENA AND SCLEROTHERAPY PROCEDURES</li><li>Excellent communication skills for liaising between providers, insurers, and patients</li><li>Office experience with proficiency in electronic health records (EHR) systems or similar software</li><li>Knowledge of medical billing procedures and familiarity with medical records management is a plus</li></ul>Join us to be part of a dedicated team committed to delivering exceptional patient care through efficient authorization processes. Your expertise will help streamline operations while supporting the health and well-being of our patients.Pay: $25.00 - $29.00 per hourWork Location: In person

Prior Authorization Specialist

The NeuroSpine Group

Company Overview The NeuroSpine Group is dedicated to providing comprehensive neurosurgical spine care within a convenient, patient-centered environment. Our team of specialized surgeons and medical professionals work collaboratively to deliver the highest quality care, ensuring seamless diagnosis, treatment, and recovery for our patients.Job Summary We are seeking an energetic and detail-oriented Prior Authorization Specialist/Scheduling professional to join our dedicated medical team. In this vital role, you will coordinate insurance authorizations, manage scheduling, and ensure smooth communication between patients, providers, and insurance companies. Your proactive approach will help facilitate timely approvals and appointments, contributing to exceptional patient experiences.Duties<ul><li>Obtain prior authorizations from managed care organizations for diagnostic tests, procedures, or treatments</li><li>Verify insurance coverage and benefits for each patient prior to scheduled appointments</li><li>Schedule patient appointments efficiently while coordinating with providers&rsquo; availability</li><li>Maintain accurate medical records, including documentation of authorization requests and approvals</li><li>Communicate clearly with patients regarding scheduling details and insurance requirements</li><li>Ensure compliance with HIPAA regulations to protect patient confidentiality at all times</li><li>Collaborate with medical office staff to streamline office workflows and improve patient service delivery</li></ul>Qualifications<ul><li>Proven experience in medical office administration or scheduling within healthcare settings</li><li>Knowledge of managed care processes, insurance verification, and prior authorization procedures</li><li>Familiarity with medical terminology, CPT coding (Current Procedural Terminology), ICD-9/ICD-10 coding systems, and medical records management</li><li>Strong understanding of HIPAA regulations to ensure confidentiality and privacy standards are met</li><li>Experience working with dental or other specialty offices is a plus</li><li>Excellent organizational skills with attention to detail and ability to multitask effectively</li><li>Prior experience in a fast-paced office environment involving medical coding and insurance processes is highly desirable</li></ul>Join us in making a difference by ensuring our patients receive timely care through efficient scheduling and authorization processes. We value proactive team members who thrive in dynamic healthcare environments!Pay: $22.00 - $29.62 per hourBenefits:<ul><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Work Location: In person

Prior Authorization Specialist/Scheduling

Signature Performance

<div><div>Position Purpose:

This position is responsible for working closely with Patient, Patient Access, Payers, and Providers' office to validate insurance plans, eligibility, and orders to procure required prior authorizations.

Organization:

This position reports to the Revenue Cycle Manager.

Essential Job Functions include the following. Other duties may be assigned.
<ul>
<li>Collaborate with insurers to obtain pre-authorizations for condition-specific medications, diagnostic procedures and treatments, and support patients in navigating barriers / coverage and disputes.</li>
<li>Submit prior authorization requests for medical procedures, diagnostic tests, treatments, and medications as required by insurance providers.</li>
<li>Gather, review, and submit all necessary clinical documentation to support authorization requests, ensuring accuracy and completeness.</li>
<li>Communicate with insurance representatives to clarify requirements, resolve authorization denials, and follow up on pending approvals.</li>
<li>Collaborate with physicians, nurses, and other clinical staff to obtain additional clinical information or documentation required by insurance companies.</li>
<li>Inform patients about the status of their authorization requests, answer questions regarding coverage, and provide guidance on next steps.</li>
<li>Maintain accurate and detailed records of all prior authorization requests, outcomes, and patient information in compliance with HIPAA regulations.</li>
<li>Stay updated on changes in insurance policies, state and federal regulations, and organizational policies affecting prior authorizations and reimbursement.</li>
<li>Meet quality and productivity standards set by Signature and/or our client.</li>
<li>Provide excellent customer service in keeping with Signature's legacy both internal and externally.</li>
<li>Maintain expertise in multiple current client systems.</li>
<li>Maintain up to date knowledge of revenue cycle management, industry trends perform other duties as necessary.</li>
<li>Acts as an effective team member.</li>
</ul>
Required Knowledge &amp; Experience:
<ul>
<li>Minimum 2 years of prior authorization experience, insurance coordination, or case management within a physician office, hospital, or insurance plan authorizations unit.</li>
<li>Understanding of healthcare insurance systems</li>
<li>Strong written and verbal communication skills with the ability to explain complex medical and insurance information</li>
<li>Strong attention to detail</li>
<li>Passion for patient advocacy with a problem-solving mindset, focusing on overcoming challenges to accessing care.</li>
<li>Ability to work effectively both independently and as part of a multidisciplinary team</li>
<li>Computer proficiency including Microsoft Office, Word, Excel and Outlook</li>
<li>Ability to function effectively in a fast-paced environment.</li>
<li>Personal traits of a high-level commitment, motivation, energy, team orientation, professionalism, trust, personal honesty and integrity, and a demonstration of placing others in a place of high value.</li>
</ul>
Preferred Knowledge &amp; Experience:
<ul>
<li>Preferred experience and understanding of medical terminology</li>
<li>General knowledge of CPT/HCPCS and ICD-10</li>
</ul>
General Areas of Accountability:

Must conduct business and personal affairs in a manner that is always a credit to the company. Must maintain a good credit rating while employed with the company.

The following HIPAA and Privacy items apply to all positions at Signature Performance:
<ul>
<li>Follow HIPAA guidelines for protecting the privacy and security of sensitive personal and/or health information.</li>
<li>Follow Signature expected acceptable use to protect propriety and company owned information.</li>
<li>Complete annually required Privacy and Security Training</li>
</ul>
PERFORMANCE MANAGEMENT:

All Signature Performance associates are subject to regular performance management to determine if skills and training requirements are suitable for the position.

Machines and Equipment:

The incumbent must be able to effectively operate the current computer system, telephone system, and other office machines such as copiers and fax machines.

SECURITY REQUIREMENTS:
<ul>
<li>U.S. Citizenship, naturalized citizenship, or permanent status is required for this position.</li>
<li>All work on all positions at Signature Performance must be completed in the continental United States, Alaska, or Hawaii.</li>
</ul>
Physical Activity:

The incumbent must be able to finger, grasp, feel, see, sit, hear, and speak. This position is sedentary in nature with minimal lifting requirements.

WORKING CONDITIONS:

The incumbent works in an office environment that is not substantially exposed to adverse environmental conditions such as heat, cold, or extreme noise. Routine periods of being on the phone utilizing a headset, sitting and data keying are required.

Remote Eligibility: This position is full-time remote eligible. Eligibility is determined by Management or Talent Operations.

The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.
</div>
Requirements:
<div><ul><li>U.S. Citizenship, naturalized citizenship, or permanent status is required for this position.</li>
<li>All work on all positions at Signature Performance must be completed in the continental United States, Alaska, or Hawaii.</li>
</ul>
</div> 
Compensation: $22-$25/hour
 
Additional Details : M-F, either 7am to 330pm or 8am to 430pmCST 
 
Full Time</div>

Squad Health

Pay: 130,000.00 (PKR) - 160,000.00 (PKR) per monthPrior Authorization Specialist (Prescription Navigator)Remote | Offshore | Full-Time | EST HoursThree options of working off-hours to choose from:Weekdays | Work Hours: 3:00 AM &ndash; 12:00 PM Pakistan Time (6:00 PM &ndash; 3:00 AM EST)Weekdays | Work Hours: 9:00 AM &ndash; 6:00 PM Pakistan Time (12:00 AM &ndash; 9:00 AM EST)Weekends | Work Hours: 6:00 PM &ndash; 2:00 AM Pakistan Time (9:00 AM &ndash; 5:00 PM EST)Compensation: $450 &ndash; $575 per month Employment Type: Direct Hire | Full-TimeAbout UsSquad Health provides navigation services and software to US medical practices to remove barriers to treatment &mdash; especially prescription access.Our services include benefits investigation, prior authorization submission, patient assistance enrollment, pharmacy coordination, and patient engagement.Our team members operate as extensions of provider offices, supporting clinical staff through accurate documentation and consistent follow-up.Job SummaryWe are seeking an experienced Prior Authorization Specialist with strong background in US specialty medication authorizations. This role requires reviewing clinical documentation, verifying insurance benefits, submitting medication authorizations, and managing denials and appeals efficiently.Duties<ul><li>Verify insurance benefits for drug and procedure orders (Commercial, Medicare, Medicaid)</li><li>Determine pharmacy vs. medical benefit requirements when applicable</li><li>Obtain appropriate authorizations by completing payer-specific forms and clinical questionnaires</li><li>Review medical notes, diagnosis information, and treatment history to answer clinical questions accurately</li><li>Submit and manage authorizations through, payer portals, fax, or phone</li><li>Track pending authorizations and follow up until resolution</li><li>Prioritize and manage STAT/urgent requests appropriately</li><li>Communicate with MDs and NPs regarding denials, treatment plan updates, and Letters of Medical Necessity (LMNs)</li><li>Assist patients with copay assistance or patient assistance programs when needed</li><li>Enroll patients into navigation programs and obtain consent</li><li>Document all actions clearly in internal systems and case trackers</li><li>Participate in team meetings to resolve patient access challenges and improve workflow</li></ul>Required Skills &amp; Experience<ul><li>Minimum 2 years of US-based specialty medication prior authorization experience</li><li>Experience managing other PA Specialists preferred</li><li>Direct experience supporting GI, Dermatology, Rheumatology, and Allergy medication authorizations required</li><li>Strong understanding of US insurance plans (Commercial, Medicare, Medicaid)</li><li>Experience reviewing EMR/EHR clinical documentation</li><li>Strong attention to detail and structured documentation habits</li><li>Fluent English (written and verbal)</li><li>Ability to work without supervision</li></ul>Work Location: RemoteJob Type: Full-timePay: Rs130,000.00 - Rs160,000.00 per monthApplication Question(s):<ul><li>List 5 medications for which you have frequently completed prior authorizations and can discuss during an interview</li><li>Indicate whether you have worked in a hospital, clinic or retail completing medication prior authorizations, and which platforms, portals, EMR systems, you have used?</li><li>Why are you looking to leave (or have already left) your previous employer?</li><li>A summary of your relevant experience in United States-based prescription prior authorizations</li></ul>Work Location: Remote

Prior Authorization Specialist (PK)

Puget Sound Home Health and Hospice

<div>Join Our Team as an Insurance Prior Authorization Specialist at Puget Sound Home Health &amp; Hospice.
Benefits:<ul><li>
$23-28 per hour, DOE</li><li>
Comprehensive Medical, Dental, and Vision insurance</li><li>
Free health concierge services</li><li>
FSA and HSA accounts</li><li>
Paid Life and AD&amp;D insurance</li><li>
Paid Sick, Holidays, and PTO</li><li>
STD, LTD, and other voluntary insurance plans</li><li>
Company-wide celebrations of your great work &amp; accomplishments</li><li>
Support for your professional growth and development</li><li>
Room for advancement</li><li>
AMAZING teammates &amp; leaders who are supportive, inclusive, and fun!</li></ul>
What Do We Require of a Prior Authorization Specialist?
<ul><li>Must have at least 1 year of insurance authorization/billing experience in a medical office, preferably home health/hospice.
</li><li>Experience with Home Care Home Base is strongly preferred</li><li>
Demonstrated cooperation and excellent customer service skills</li><li>
Ability to multi-task and stay on task in a fast-paced office</li><li>
Excellent team-oriented, verbal, and written communication skills</li></ul>
Key Responsibilities:<ul><li>
Verify insurance coverage, including primary and secondary payors</li><li>
Use UGS/DDE and EDS programs to verify Medicare/Medicaid eligibility</li><li>
Obtain visit authorization via payor by providing appropriate medical records</li><li>
Perform accurate data entry in patient records within HCHB</li><li>
Maintain payor files with up-to-date requirements to obtain/initiate appeals for denied authorizations</li><li>
Interface with contract, clinical, and office staff to foster collaboration and positive working relationships</li><li>
Prepare patient co-pay estimates and notify scheduling of authorized visits</li><li>
Provide excellent customer service to patients, referral sources, and community contacts with questions regarding payor prior authorizations and medical guidelines</li><li>
Enter, audit, and follow up on authorized and unauthorized visits within HCHB</li></ul>
Why Puget Sound Home Health &amp; Hospice?
At Puget Sound Home Health &amp; Hospice, we pride ourselves on our quality of care and ethical business practices, guided by our foundational Core Values of CAPLICO:<ul><li>
Customer Second (Employee First!)</li><li>
Accountability</li><li>
Passion for Learning</li><li>
Love One Another</li><li>
Intelligent Risk Taking</li><li>
Celebration</li><li>
Ownership</li></ul>
www.pugetsoundhhh.com<div><div><div><div><div><div><div><div><div><div><div><div><div><div>
The employer for this position is stated in the job posting. The Pennant Group, Inc. is a holding company of independent operating subsidiaries that provide healthcare services through home health and hospice agencies and senior living communities located throughout the US. Each of these businesses is operated by a separate, independent operating subsidiary that has its own management, employees and assets. More information about The Pennant Group, Inc. is available at http://www.pennantgroup.com.</div></div></div></div></div></div></div></div></div></div></div></div></div></div></div>

Prior Authorizations Specialist

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10000 prior authorization nurse jobs Near Me

Care Review Clinician (RN)

Prior Authorization Pharmacist - Connecticut Medicaid (Remote)

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Prior Authorization Specialist

Prior Authorization Specialist (PK)

Prior Authorizations Specialist