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Prior Authorization Rn Jobs in Pittsburgh, PA (NOW HIRING)

Excela Health

REGISTERED NURSE RN

Greensburg, PA · On-site

The RN coordinates, directs, and actively participates as an effective member of the ... Obtains prior authorizations and/or assists with indigent programs per physician order based on the ...

Excela Health

REGISTERED NURSE RN

Greensburg, PA · On-site

The RN coordinates, directs, and actively participates as an effective member of the ... Obtains prior authorizations and/or assists with indigent programs per physician order based on the ...

Excela Health

REGISTERED NURSE RN

Greensburg, PA

The RN coordinates, directs, and actively participates as an effective member of the ... Obtains prior authorizations and/or assists with indigent programs per physician order based on the ...

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All JobsPrior Authorization Rn JobsPrior Authorization Rn Jobs in Pittsburgh, PA

Prior Authorization Rn information

See Pittsburgh, PA salary details

$7

$41

$70

How much do prior authorization rn jobs pay per hour?

As of Aug 5, 2026, the average hourly pay for prior authorization rn in Pittsburgh, PA is $41.01, according to ZipRecruiter salary data. Most workers in this role earn between $30.58 and $48.56 per hour, depending on experience, location, and employer.

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

AspectPrior Authorization RnMedical Coder
CredentialsRN license, possibly certifications in case management or utilization reviewCertification in coding (CPC, CCS), no RN license required
Work EnvironmentHospitals, insurance companies, healthcare facilitiesMedical offices, hospitals, insurance companies
Primary ResponsibilitiesReviewing and obtaining prior authorizations for treatments and proceduresTranslating medical records into coded data for billing and documentation

While both roles are integral to healthcare administration, the Prior Authorization RN focuses on obtaining approvals for patient care, requiring nursing credentials and clinical knowledge. In contrast, Medical Coders specialize in coding medical records for billing, emphasizing coding certifications. Understanding these differences helps healthcare professionals and job seekers identify the right career path or job opportunity.

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

To thrive as a Prior Authorization RN, you need a current RN license, strong clinical assessment skills, and a solid understanding of insurance guidelines and medical necessity criteria. Familiarity with utilization management software, electronic health records (EHRs), and payer-specific authorization systems is essential. Exceptional attention to detail, critical thinking, and effective communication help you advocate for patients and collaborate with healthcare providers and insurers. These skills ensure the efficient processing of authorizations, reduce delays in care, and support patients in receiving appropriate treatments.

What does a Prior Authorization RN do?

A prior authorization RN is a registered nurse who assesses applications for specific treatments, medical procedures, and medications. In this job, you review each request for medical coverage and determine the necessity or potential benefits of the treatment or medicine. You assess patient information and other factors to decide whether or not to authorize coverage. Your duties as a prior authorization RN also include reviewing denials of benefits and seeking additional information that could alter the initial decision. You document your findings for each case and present the evidence along with your decision. It is your job to review the case for each patient thoroughly while following all government regulations and healthcare provider policies.

What are some common challenges faced by Prior Authorization RNs, and how can they be addressed?

Prior Authorization RNs often navigate complex insurance guidelines and manage high volumes of requests, which can be challenging due to frequent policy updates and tight timelines. Staying organized, maintaining up-to-date knowledge of payer requirements, and leveraging electronic health record (EHR) systems can help streamline the process. Collaboration with providers and insurance representatives, as well as ongoing training, are essential for efficiently resolving issues and ensuring timely patient care.

What is a Prior Authorization RN?

A Prior Authorization RN is a registered nurse who specializes in reviewing and processing prior authorization requests for medical procedures, medications, or treatments. They evaluate clinical documentation to determine if requests meet insurance or regulatory criteria and often serve as a liaison between healthcare providers, patients, and insurance companies. Their role helps ensure that care is medically necessary and covered by the patient's health plan, streamlining access to important healthcare services while controlling costs.
More about Prior Authorization Rn jobs
What are the most commonly searched types of Prior Authorization Rn jobs in Pittsburgh, PA? The most popular types of Prior Authorization Rn jobs in Pittsburgh, PA are:
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What cities near Pittsburgh, PA are hiring for Prior Authorization Rn jobs? Cities near Pittsburgh, PA with the most Prior Authorization Rn job openings:
Prior Authorization Rn jobs near you
Infographic showing various Prior Authorization Rn job openings in Pittsburgh, PA as of July 2026, with employment types broken down into 100% Full Time. Highlights an 59% In-person, 10% Hybrid, and 31% Remote job distribution, with an average salary of $85,303 per year, or $41 per hour.

Clinical Pharmacy Specialist (Remote)- Prior Authorization Team!

UPMC Health Plan

Pittsburgh, PA • Remote

$122K - $142K/yr

Other

Posted 16 days ago

Job description

UPMC Health Plan is hiring a full-time Clinical Pharmacy Specialist to support the Prior Authorization Team within the Pharmacy Services department. This is a work-from-home position. This is a daylight position working between the hours of 8:00 a.m. - 5:00 p.m. EST. Must be licensed in PA.

Registration as a registered pharmacist (RPh), in the Commonwealth of Pennsylvania or eligibility for licensure by examination or reciprocity is required.

The Clinical Pharmacy Specialist provides clinical pharmacy expertise to the development, implementation, and management of the pharmacy benefit.The clinical pharmacist assists in the management of pharmacy utilization and provides expertise in managing member care through the prior authorization and appeals process for medications. These services will be provided in compliance with state and federal regulations including NCQA and CMS standards while upholding the mission, policies and procedures of UPMC Health Plan and Pharmacy Department. Individual candidates should demonstrate professionalism and commitment to meet UPMC HP goals and objectives.

Must be legally authorized to work in the United States, without requiring, now or in the future, sponsorship for employment visa status. UPMC does not participate in STEM OPT.

Responsibilities:

The Prior Authorization Pharmacist primary responsibilities include:

  • Perform the clinical review of Prior Authorization, Step Therapy, Quantity Limit, and all other pharmacy utilization management requests in accordance with quality, timeliness, and efficiency standards.
  • Critically review pharmacy utilization management requests for approval/denial against standard clinical criteria and regulatory approved policies.
  • Participate in a clinical call queue to receive inquiries from internal and external stakeholders pertaining to the exception process while answering in a timely, accurate and professional manner.
  • Participate in the pharmacy appeals process through the review of denied cases as well as serving as committee representation at fair hearings.
  • Participate in and contribute to other operational initiatives on an as needed basis.

Additional responsibilities and attributes include:

  • Foster and maintain collaborative relationships with internal and external customers.
  • Perform job duties independently, reliably, efficiently, accurately, and professionally while supporting a virtual team concept.
  • Demonstrate keen drug information skills to adequately research drugs and disease states pertaining to complex utilization management reviews or other ancillary responsibilities.
  • Utilize a home office set-up that honors client and patient confidentiality.
  • Maintain a foundational understanding of the requirements of the Pennsylvania Department of Human Services (DHS), Centers for Medicare & Medicaid Services (CMS), Pennsylvania Insurance Department (PID), and the National Committee for Quality Assurance (NCQA), as they relate to the compliance and regulatory requirements of clinical operational functions.
  • Participate in meetings, committees, and work groups as assigned.
  • Mentor students, residents, and other pharmacists (If applicable).
  • Bachelor of Science Degree in Pharmacy, and/or Doctor of Pharmacy Degree (Pharm.D.) from an accredited U.S. School of Pharmacy.
  • Experience in pharmacy benefit management, insurance, managed care preferred and be knowledgeable in therapeutic interventions and other cost containment programs.
  • Effective communication skills, both written and oral.
  • Must have strong analytical ability and organizational skills.
  • Computer literacy for pharmacy programming, word processing, data management.
  • Assessment of job related skills and competency will be reviewed annually via daily functioning, job-related documentation, department based competency programs, and continuing education activities.

Preferred Experience:
Experience with claims adjudication, therapeutic substitution interventions, dose optimization and other cost containment programs is preferred. Experience in pharmacy benefit management, insurance, managed care such as completion of a managed care residency or 1-3 years managed care experience is preferred but not required.
Licensure, Certifications, and Clearances:
Registration as a registered pharmacist (RPh), in the Commonwealth of Pennsylvania or eligibility for licensure by examination or reciprocity.Continuing Education requirements met each bi-annual cycle for re-licensure, as evident by obtaining a minimum of 30 hours of continuing education every 2 years in structured pharmaceutical education as necessary by the state board.

  • Pharmacist
  • Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran

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