Utilization Review and Preauthorization Nurse

The Utilization Review and Preauthorization Specialist plays a vital role in overseeing prior authorization and utilization review processes. This position ensures that medical services are evaluated for medical necessity, benefit eligibility, and plan compliance before care is delivered. Serving as a key liaison between providers, members, and internal departments, the Specialist facilitates efficient processing, supports quality care outcomes, and ensures adherence to regulatory and accreditation standards.

• Receive, review, and process prior authorization requests for inpatient/outpatient services, procedures, imaging, medications, and durable medical equipment (DME).
• Verify member eligibility and benefit coverage in accordance with health plan policies.
• Apply MCG (Milliman Care Guidelines) or equivalent clinical criteria to assess medical necessity for routine inpatient/outpatient services.
• Approve or escalate requests based on clinical appropriateness, benefit guidelines, and established criteria.
• Route complex inpatient, outpatient, specialty, or high-cost service requests to the appropriate clinical reviewer (Medical Director, Nurse Manager, or Care Manager).
• Obtain, review, and synthesize supporting clinical documentation to support authorization determinations.
• Maintain accurate, timely records and notes in the utilization management system.
• Summarize medical records and clinical findings to document rationale for approvals, denials, or modifications.

• Communicate authorization decisions clearly, professionally, and within required timeframes to providers, members, and internal stakeholders.
• Deliver responsive, compassionate service to address inquiries and concerns from providers and members.
• Educate providers and internal staff on authorization processes, plan requirements, and clinical documentation standards.
• Respond to and resolve authorization-related issues and escalations in a timely manner.

• Ensure adherence to HIPAA, URAC, NCQA, and health plan-specific regulatory and accreditation standards.
• Monitor turnaround times for authorization decisions to maintain compliance with internal policies and external requirements.
• Maintain comprehensive, accurate documentation of all authorizations, correspondence, and decision rationales.

• Collaborate effectively with Care Coordination, Case Management, Claims, and Customer Service teams to support coordinated, high-quality care.
• Participate in quality improvement initiatives and ongoing professional development.
• Identify patterns and trends in utilization requests and share insights with leadership to inform policy, workflow, and system improvements.

• Associate or bachelor’s degree in a healthcare-related field preferred.
• Registered Nurse (RN) preferred; other clinical professional certification with relevant experience considered.
• Minimum of 2 years of experience in a medical office, utilization review, preauthorization, or medical billing setting within a payer or provider organization.
• Familiarity with MCG, InterQual, or comparable clinical decision-support tools preferred.
• Strong working knowledge of CPT, HCPCS, and ICD-10 coding systems highly desirable.

• Strong critical thinking and analytical skills; ability to interpret clinical documentation and apply plan benefits accurately.
• Excellent verbal and written communication abilities.
• Exceptional attention to detail, organization, and the ability to manage multiple priorities in a fast-paced environment.
• Proficient in Microsoft Office applications (Word, Excel, Outlook).
• Experience working with electronic utilization management systems required.

• Standard office environment
• Working hours 8 – 5, Monday through Friday
• Position is performed in the office