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Prior Authorization Utilization Review Jobs in Kansas

US Tech Solutions

Registered Nurse

Wichita, KS · On-site

Do you have experience with Prior Authorization? * Do you have experience with Utilization Review? * Do you have an Active Registered Nurse License? About US Tech Solutions: US Tech Solutions is a ...

Lone Peak Hospital

Authorization Coordinator

Olathe, KS · On-site

$18 - $22.25/hr

Responsible for review and completion of prior authorizations to ensure timeliness of appointments, testing, procedures, and claims filing. * Obtain clinical information (including but not limited to ...

Mission Hospital

Authorization Coordinator

Olathe, KS · On-site

$18 - $22.25/hr

Responsible for review and completion of prior authorizations to ensure timeliness of appointments, testing, procedures, and claims filing. * Obtain clinical information (including but not limited to ...

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Prior Authorization Utilization Review information

What is a Prior Authorization Utilization Review specialist?

A Prior Authorization Utilization Review specialist is a healthcare professional responsible for evaluating medical service requests to ensure they meet specific criteria for approval before services are provided. Their main role is to review clinical information, verify medical necessity, and ensure compliance with insurance policies and guidelines. They act as a liaison between healthcare providers, insurance companies, and patients to facilitate timely and accurate authorization decisions. This process helps to manage healthcare costs and ensure patients receive appropriate care.

What are the key skills and qualifications needed to thrive as a Prior Authorization Utilization Review specialist?

To thrive as a Prior Authorization Utilization Review Specialist, you need a strong understanding of medical terminology, insurance guidelines, and clinical criteria, often supported by a degree in healthcare or nursing and relevant certification (such as RN or LPN). Familiarity with prior authorization software, electronic health record (EHR) systems, and payer portals is typically required. Attention to detail, strong communication skills, and the ability to multitask help professionals excel in this role. These competencies ensure accurate and timely processing of authorizations, reducing delays in patient care and ensuring compliance with payer requirements.

What are some common challenges faced by professionals in Prior Authorization Utilization Review roles, and how can these be managed?

Professionals in Prior Authorization Utilization Review often encounter challenges such as navigating complex insurance policies, managing high volumes of requests, and ensuring timely communication between providers and payers. Staying organized, developing a thorough understanding of payer guidelines, and maintaining clear, consistent communication are key strategies for managing these challenges. Many teams also rely on workflow management tools and regular team huddles to streamline processes and ensure all cases are handled efficiently.

What is the difference between Prior Authorization Utilization Review vs Medical Reviewer?

AspectPrior Authorization Utilization ReviewMedical Reviewer
CredentialsLicensed healthcare professionals, often with certifications in utilization reviewLicensed physicians or healthcare providers with clinical expertise
Work EnvironmentInsurance companies, healthcare organizations, or third-party review firmsHospitals, clinics, insurance companies, or consulting firms
Primary FocusAssessing the necessity of procedures or treatments before approvalEvaluating clinical records to determine medical necessity and appropriateness

While both roles involve clinical assessment, Prior Authorization Utilization Review focuses on pre-authorization decisions for treatments, whereas Medical Review involves detailed clinical evaluation of patient records to determine medical necessity. Both require healthcare credentials and are integral to healthcare quality and cost management.

What are popular job titles related to Prior Authorization Utilization Review jobs in Kansas?

For Prior Authorization Utilization Review jobs in Kansas, the most frequently searched job titles are:

What job categories do people searching Prior Authorization Utilization Review jobs in Kansas look for?

The top searched job categories for Prior Authorization Utilization Review jobs in Kansas are:

Prior Authorization Utilization Review jobs near you
Infographic showing various Prior Authorization Utilization Review job openings in Kansas as of August 2026, with employment types broken down into 100% Full Time. Highlights an 100% In-person job distribution.

Registered Nurse

US Tech Solutions

Wichita, KS • On-site

Other

Re-posted 20 days ago

Job description

Wichita, KS

Contract

Job Description:

  • Participates in the development and ongoing implementation of QM Work Plan activities.

  • Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives

Responsibilities:

  • Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.

  • Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.

  • Data gathering requires navigation through multiple system applications.

  • Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.

  • Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.

  • Responsible for the review and evaluation of clinical information and documentation.

  • Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.

  • Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).

  • Independently coordinates the clinical resolution with internal/external clinician support as required.

  • Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data

  • Prepares and completes QM documents based on interpretation and application of business requirements

  • Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements

  • Assists in the development and implementation of QM projects and activities

  • Accountable for completing and implementation of QM Work Plan Activities

Experience:

  • 3+ years of experience as an RN

  • Registered Nurse in state of residence

  • Must have prior authorization utilization experience

  • Experience with Medcompass

Skills:

  • MUST HAVE MEDCOMPASS or ASSURECARE exp.

  • MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.

  • MUST HAVE UM experience, inpatient utilization management review.

  • MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.

  • MUST HAVE 6 months of Prior Authorization.

Education:

  • Active and unrestricted RN licensure in state of residence

Questionnaire:

  • Do you have experience with Medcompass?

  • Do you have experience with Prior Authorization?

  • Do you have experience with Utilization Review?

  • Do you have an Active Registered Nurse License?

About US Tech Solutions:

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com (http://www.ustechsolutionsinc.com) .

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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About US Tech Solutions

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US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions.

Industry

It services

Company size

1,001 - 5,000 Employees

Headquarters location

Jersey City, NJ, US

Year founded

2000

Social media

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