Prior Authorization Registered Nurse

Responsibilities

Northwind Pharmaceuticals is seeking a Prior Authorization Nurse who will review Prior Authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate stakeholders for clinical determinations.

Completes medical necessity reviews for requested services using clinical judgment and refers to internal stakeholders for review depending on case findings.

Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.

Enters and maintains pertinent clinical information and documentation in the medical management systems.

Provides feedback on opportunities to improve the authorization review process for members.

Understands own work area professional concepts/standards, regulations, strategies, and operating standards.

Makes decisions regarding own work approach/priorities and follows direction.

Requirements

Registered Nurse, RN, license without restrictions or disciplinary action.

Minimum Two (2) years clinical nursing experience in acute or outpatient care.

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.

Ability to work independently under general instructions and with a team.