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From Home Prior Authorization Rn Jobs in Arizona

Medasource

Prior Authorization RN Reviewer

Phoenix, AZ · On-site

The Prior Authorization RN is responsible for reviewing and processing medical prior authorization requests to ensure services are medically necessary, meet evidence-based guidelines, and align with ...

Onco360

Pharmacy Prior Authorization Specialist

Scottsdale, AZ · On-site +1

$20.75 - $26.75/hr

... from insurance carriers by receiving prescriptions, addressing and rectifying rejected claims and conducting necessary third party authorization requests. How You'll Do This * Manage prior ...

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All JobsPrior Authorization Rn JobsFrom Home Prior Authorization Rn JobsFrom Home Prior Authorization Rn Jobs in Arizona

From Home Prior Authorization Rn information

What is the difference between From Home Prior Authorization Rn vs From Home Medical Coder?

AspectFrom Home Prior Authorization RnFrom Home Medical Coder
CredentialsRN license, possibly certifications like CCMMedical coding certification (CPC, CCS)
Work EnvironmentHome-based, clinical settingHome-based, administrative setting
Industry UsageHealthcare, insurance, patient careHealthcare, billing, insurance claims

While both roles are remote healthcare positions, From Home Prior Authorization Rn focuses on reviewing medical necessity for insurance approvals, requiring nursing credentials. In contrast, From Home Medical Coder handles medical billing and coding, requiring coding certifications. Both roles support healthcare operations but differ in responsibilities and required qualifications.

What cities in Arizona are hiring for From Home Prior Authorization Rn jobs? Cities in Arizona with the most From Home Prior Authorization Rn job openings:
From Home Prior Authorization Rn jobs near you
Prior Authorization RN Reviewer

Prior Authorization RN Reviewer

Medasource

Phoenix, AZ • On-site

Other

Posted 7 days ago

Job description

POSITION SUMMARY: The Prior Authorization RN is responsible for reviewing and processing medical prior authorization requests to ensure services are medically necessary, meet evidence-based guidelines, and align with the health plan’s policies. This RN plays a critical role in supporting cost-effective care while ensuring quality and compliance in alignment with regulatory and accreditation standards.


CORE FUNCTIONS

1. Manages health Plan consumer/beneficiaries across the health care continuum to achieve optimal clinical, financial, operational, and satisfaction outcomes.


2. Provides pre-service determinations, concurrent review, and case management functions within Medical Management. Ensures quality of service and consistent documentation.


3. Works collaboratively with both internal and external customers in assisting health Plan consumers/beneficiaries and providers with issues related to prior authorization, utilization management, and/or case management. Meets internal and external customer service expectations regarding duties and professionalism.


4. Performs transfer of accurate, pertinent patient information to support the pre-service determination(s), the transition of patient care needs through the continuum of care, and performs follow-up calls for advanced care coordination. Documents accurately and timely, all interventions and necessary patient-related activities in the correct medical record.


5. Evaluates the medical necessity and appropriateness of care, optimizing health Plan consumer/beneficiary outcomes. Identifies issues that may delay patient services and refers to case management, when indicated, to facilitate resolution of these issues, pre-service, concurrently, and post-service.


6. Provides ongoing education to internal and external stakeholders who play a critical role in the continuum of care model. Training topics consist of population health management, evidence-based practices, and all other topics that impact medical management functions.


7. Identifies and refers requests for services to the appropriate Medical Director and/or other physician clinical peer when guidelines are not clearly met. Conducts call rotation for the health plan, as well as departmental call rotation for holidays.


8. Maintains a thorough understanding of each plan, including the Evidence of Coverage, Summary Plan Description, authorization requirements, and all applicable federal, state, and commercial criteria, such as CMS, MCG, and Hayes.


Minimum Qualifications:

  • Active RN license -- AZ License or Compact State License
  • Experience working in inpatient & outpatient settings
  • Focus on Outpatient Prior Auths for surgeries and DME (Durable Medical Equipment)
  • Medicare review experience is highly preferred
  • Experience with reviewing guidelines (this position is more pre-service)
  • Experience with MCG criteria, CareWebQI & Interqual
  • Utilization Management experience required
  • Payer background major plus

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