Prior Authorization Associate Jobs in Birmingham, AL

In Clinical Documentation Integrity at Main Campus Lee Building
Work schedule will be Full-time on the Day Shift, Monday-Friday.
Summary:
The Outpatient Clinical Documentation Integrity (CDI) Specialist Nurse will provide clinically based reviews of outpatient medical records to assess and procure accurate, complete, and compliant documentation of the patients' visit encounter. The goal is to facilitate clinically appropriate physician and other clinician documentation of all patient conditions, treatments, and interventions to accurately reflect quality of care, severity of illness, risk of morality and risk adjustment factor to support correct coding, reimbursement, and quality initiatives. The goal of CDI outpatient reviews is to facilitate clinically appropriate physician/ clinician documentation of all patient conditions, treatments, and interventions to accurately reflect quality of care, severity of illness and risk of morality and risk adjustment factor to support correct coding, reimbursement, and quality initiatives. This role will work closely with all levels of leadership, subject matter experts, and operational stakeholders to remain compliant with state and federal regulatory codes and guidelines.
Other information:
Minimum Requirements
• Registered Nurse (RN) preferred
• Current RN or LPN Licensure in the State of Alabama required
Experience
• At least five years of nursing experience required (3 of these years must be in acute or intensive care setting), prefer pediatric experience. Will consider CDI experience in lieu of pediatric experience.
Licensures, Certifications, and/or Registries
• CCDS and/or Coding certification (ex. CPC) highly desired or willingness to complete after employment.
Credentials with Equivalent Qualifications:
Essential:
* Registered Nurse AL Single State or any of the following equivalent qualifications below:
- Registered Nurse AL NLC Multi State
- Registered Nurse Non-AL NLC Multi State
Nonessential:
* Certified Coding Specialist or Certified Coding Associate
Education with Equivalent Qualifications:
Essential:
* Bachelor of Science Nursing in Nursing or Associate of Science Nursing in Nursing
Experience with Equivalent Qualifications:
Essential:
* 5 Years job experience as Staff Level with specialization in the field of Nursing Acute
The Clinical Documentation Integrity (CDI) department plays a key role within the Revenue Cycle by ensuring the accuracy and integrity of clinical documentation and related processes. The department encompasses several specialized areas: Inpatient and Outpatient CDI, Infusion Prior Authorizations, Medical Audit, and Medicaid Screening. Each area is staffed by experienced nurses who review medical records for various clinical and regulatory purposes. Inpatient and Outpatient CDI Nurses conduct concurrent and retrospective reviews of medical records to ensure documentation accurately reflects the patient's clinical status, severity of illness, and treatments. Their work supports appropriate coding, reimbursement, and compliance, while also providing ongoing documentation education to physicians and clinical staff. Infusion Prior Authorization Nurses manage prior authorization requests for outpatient infusions, including those requiring peer-to-peer reviews or appeals. They collaborate closely with Billing on denials and appeals to support timely patient care and reimbursement. Medical Audit Nurses perform chart audits to ensure hospital charges are appropriate and compliant. They identify billing trends, correct discrepancies, and support hospital departments with charge integrity. Medicaid Screening Nurses focus on EPSDT and Interperiodic Screenings for patients with Medicaid coverage. Their detailed reviews ensure compliance with state and federal Medicaid regulations. Together, these teams support clinical excellence, regulatory compliance, and financial sustainability through comprehensive documentation and review processes.