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Prior Authorization Review Nurse Jobs (NOW HIRING)

Managed Staffing

Prior Authorization Techician

RI · Remote

$21 - $22/hr

Document reviews accurately, completely, and in a timely manner. * Transfer all clinical questions ... are, PBM, or Prior Authorization related. - This experience must be clearly visible on the ...

PainPoint

Prior Authorization Coordinator

Atlanta, GA · On-site +1

$19 - $21/hr

Review medical necessity guidelines for procedures by Paycor. * Accurately and promptly submit prior and retro authorization requests to payors. * Document account activity, updating patient and ...

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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 1, 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 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 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 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.

More about Prior Authorization Review Nurse jobs
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? The top searched job categories for Prior Authorization Review Nurse jobs are:
Prior Authorization Review Nurse jobs near you
Infographic showing various Prior Authorization Review Nurse job openings in the United States as of July 2026, with employment types broken down into 1% As Needed, 87% Full Time, 10% Part Time, and 2% Contract. Highlights an 92% Physical, 3% Hybrid, and 5% Remote job distribution, with an average salary of $80,321 per year, or $38.6 per hour.

Clinical Review Nurse - Prior Authorization

Akido

Chino, CA

$62K - $93K/yr

Full-time

Re-posted 3 days ago

Job description

Akido builds AI-powered doctors. Akido is the first AI-native care provider, combining cutting-edge technology with a nationwide medical network to address America's physician shortage and make exceptional healthcare universal. Its AI empowers doctors to deliver faster, more accurate, and more compassionate care.

Serving 500K+ patients across California, Rhode Island, and New York, Akido offers primary and specialty care in 26 specialties—from serving unhoused communities in Los Angeles to ride-share drivers in New York.

Founded in 2015 (YC W15), Akido is expanding its risk-bearing care models and scaling ScopeAI, its breakthrough clinical AI platform. Read more about Akido's $60M Series B. More info at Akidolabs.com.

The Opportunity

  • The Clinical Review Nurse – Prior Authorization 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. This role focuses exclusively on prior authorization activities within the Utilization Management (UM) department and 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
  • 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

Who you are

  • Active California LVN or RN license
  • 3-5+ years of current clinical UM review
  • Experience with prior authorization in managed care or delegated environment
  • 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)
  • 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-pace environment
Salary range
$62,400—$93,600 USD

Akido Labs, Inc. is an equal opportunity employer, and we encourage qualified applicants of every background, ability, and life experience to contact us about appropriate employment opportunities.