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Prior Authorization Review Nurse Jobs (NOW HIRING)

Leon Medical Centers

Concurrent Review Nurse

Miami, FL · On-site

Concurrent Review Nurse Under the general supervision of the Director of Health Services, the ... Oversee the quality, accuracy, and timeliness of prior authorization reviews and ensure appropriate ...

Leon Health, Inc.

Concurrent Review Nurse

Miami, FL · On-site

Oversee the quality, accuracy, and timeliness of prior authorization reviews and ensure appropriate ... Bachelor's degree in Nursing required Experience * Minimum of two (2) years of experience in ...

Leon Health, Inc.

Concurrent Review Nurse

Doral, FL · On-site

Oversee the quality, accuracy, and timeliness of prior authorization reviews and ensure appropriate ... Bachelor's degree in Nursing required Experience * Minimum of two (2) years of experience in ...

Leon Health Plan

Concurrent Review Nurse

Doral, FL · On-site

Oversee the quality, accuracy, and timeliness of prior authorization reviews and ensure appropriate ... Bachelor's degree in Nursing required Experience * Minimum of two (2) years of experience in ...

Mindlance

Prior Authorization Technician I

Philadelphia, PA · On-site

$17.75 - $21.50/hr

Essential Functions • Interprets and applies clinical criteria during the prior authorization review process and approves requests if applicable • Utilizes member claims history during the prior ...

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Prior Authorization Review Nurse information

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How much do prior authorization review nurse jobs pay per hour?

As of Aug 25, 2026, the average hourly pay for prior authorization review nurse in the United States is $38.62, according to ZipRecruiter salary data. Most workers in this role earn between $29.57 and $43.27 per hour, depending on experience, location, and employer.

What does a Prior Authorization Review Nurse do?

A Prior Authorization Review Nurse is a registered nurse who evaluates medical requests from healthcare providers to determine if certain procedures, medications, or treatments qualify for insurance coverage. They review medical records, guidelines, and insurance policies to ensure requests meet necessary criteria. Their role is crucial in helping patients receive appropriate care while ensuring adherence to insurance requirements and cost management. They often communicate with providers, patients, and insurance companies to clarify or obtain additional information as needed.

What are the key skills and qualifications needed to thrive as a Prior Authorization Review Nurse, and why are they important?

To thrive as a Prior Authorization Review Nurse, you need a strong clinical background as a registered nurse (RN), in-depth knowledge of medical terminology, and experience with utilization management. Familiarity with prior authorization software, electronic health records (EHRs), and payer guidelines is typically required, along with certification such as CCM or CPUR being advantageous. Exceptional attention to detail, analytical thinking, and effective communication skills help in evaluating requests and coordinating with providers and insurers. These skills ensure accurate review processes, timely approvals or denials, and compliance with regulatory standards, ultimately supporting patient care and organizational efficiency.

What are some common challenges faced by Prior Authorization Review Nurses, and how can they be managed?

Prior Authorization Review Nurses often encounter challenges such as navigating complex insurance policies, staying updated with frequently changing payer requirements, and managing high volumes of authorization requests. Effective communication with physicians, patients, and insurance representatives is crucial to ensure timely and accurate approvals. Staying organized, leveraging electronic health record systems, and participating in ongoing training can help manage these challenges and support efficient workflow in this fast-paced environment.

What is the difference between Prior Authorization Review Nurse vs Utilization Review Nurse?

AspectPrior Authorization Review NurseUtilization Review Nurse
CredentialsRN license, certifications in case management or healthcareRN license, certifications in utilization review or case management
Work EnvironmentInsurance companies, healthcare providers, or third-party review organizationsHospitals, insurance companies, or healthcare facilities
Primary FocusReview and approve prior authorization requests for specific treatments or proceduresAssess overall medical necessity and appropriateness of care during utilization review

While both roles involve reviewing patient care, the Prior Authorization Review Nurse primarily focuses on approving specific treatment requests before services are provided, whereas the Utilization Review Nurse evaluates the overall necessity and efficiency of ongoing care. Both roles require nursing credentials and work within healthcare or insurance settings, but their specific responsibilities differ in scope and timing.

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What states have the most Prior Authorization Review Nurse jobs?

States with the most job openings for Prior Authorization Review Nurse jobs include:

What job categories do people searching Prior Authorization Review Nurse jobs look for?

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Prior Authorization Review Nurse jobs near you
Infographic showing various Prior Authorization Review Nurse job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 80% Full Time, 16% Part Time, 1% Temporary, and 2% Contract. Highlights an 92% Physical, 1% Hybrid, and 7% Remote job distribution, with an average salary of $80,321 per year, or $38.6 per hour.

Clinical Review Nurse - Prior Authorization

Chino, CA • On-site

Akido
See more jobs at Akidoexternal

Full-time

Re-posted 27 days ago

Job description

The Opportunity

  • The Clinical Review Nurse - Prior Authorization & Case Management is responsible for reviewing and processing prior authorization requests to ensure medical necessity, appropriate level of care, and compliance with health plan and regulatory requirements, as well as supporting complex case management for members with ongoing or high-risk care needs. This role is primarily focused on prior authorization review, with secondary responsibility for complex case management as the program grows within the Utilization Management (UM) department, and it supports delegated UM operations in a California managed care environment. The Clinical Review Nurse works closely with providers, Medical Directors, and operational teams to ensure timely and accurate authorization determinations in accordance with established clinical guidelines and delegation standards.

What you'll do

  • Review and process prior authorizations for outpatient services, procedures, diagnostic testing, specialty referrals, and DME and ancillary services
  • Evaluate requests using MCG guidelines and health plan criteria and policies
  • Review medical records and supporting clinical documentation to ensure completeness, accuracy, and medical necessity in accordance with established clinical guidelines and health plan requirements
  • Identify missing or insufficient documentation and coordinate with providers for additional information
  • Support case management for members with complex or high-risk care needs, including care coordination and follow-up
  • Ensure all clinical determinations are properly documented in the system
  • Maintain compliance with DMHC prior authorization requirements, CMS guidelines, health plan delegation standards, turnaround times, notification requirements, and documentation standards
  • Communicate with physicians, medical groups, facilities, and ancillary providers to obtain additional clinical information and provide authorization status updates as needed
  • Identify cases requiring clinical review and prepare clinical summaries for Medical Director determination
  • Ensure cases requiring denial are routed appropriately to the Medical Director
  • Document all authorization activities accurately within EZCap, maintaining detailed notes, status updates, and decision rationale
  • Collaborate with UM Coordinators, Claims, Eligibility, and Operations
  • Conduct comprehensive assessments and contribute to development of patient-centered care plans in collaboration with Medical Director
  • Perform monthly care management outreach, medication review, and specialist/community resource coordination, documenting time and activities

Who you are

  • Active California RN license (required)
  • 3-5+ years of current clinical UM review
  • Experience with prior authorization in managed care or delegated environment
  • Experience with complex case management
  • Knowledge of MCG criteria, medical necessity review, and prior authorization workflows
  • Experience with EZCap (preferred)
  • Experience in a delegated MSO or health plan environment (preferred)
  • Certified Case Manager (CCM) preferred
  • Knowledge of California managed care regulations (DMHC/CMS)
  • Strong clinical assessment skills and attention to detail
  • Effective written and verbal communication
  • Ability to manage competing priorities in a fast-paced environment

Apply