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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 Minnesota?

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

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

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

What cities in Minnesota are hiring for Prior Authorization Utilization Review jobs?

Cities in Minnesota with the most Prior Authorization Utilization Review job openings:

Prior Authorization Utilization Review jobs near you
Infographic showing various Prior Authorization Utilization Review job openings in Minnesota as of August 2026, with employment types broken down into 1% As Needed, 77% Full Time, 19% Part Time, 1% Temporary, and 2% Contract. Highlights an 94% Physical, 1% Hybrid, and 5% Remote job distribution.

Precertification and Authorization Rep-Hybrid

Mayo Clinic

Rochester, MN • Hybrid

$16.50 - $21.25/hr

Full-time

Medical, Dental, Vision, Retirement

Re-posted 6 days ago

Mayo Clinic rating

7.8

Company rating: 7.8 out of 10

Based on 705 frontline employees who took The Breakroom Quiz

135th of 898 rated healthcare providers

Job description

HYBRID: This is a hybrid position and must be located within 100 miles of any of the Mayo Clinic campuses for on-site expectations based on business needs.

The Precertification and Authorization Representative is an intermediate level position that is responsible for resolving referral, precertification, and/or prior authorization to support insurance specific plan requirements for all commercial, government and other payors across hospital (inpatient & outpatient), ED, and clinic/ambulatory environments. In addition, this position may be responsible for pre-appointment insurance review (PAIR) and denials recovery functions within the Patient Access department. This may include processing of pre-certification and prior authorization for workers compensation/third party liability (WC/TPL), managed care and HMO accounts, as well as working assigned registration denials for government and non-government accounts. This role requires adherence to quality assurance guidelines as well as established productivity standards to support the work unit's performance expectations.

Why Mayo Clinic

Mayo Clinic is top-ranked in more specialties than any other care provider according to U.S. News & World Report. As we work together to put the needs of the patient first, we are also dedicated to our employees, investing in competitive compensation and comprehensive benefit plans - to take care of you and your family, now and in the future. And with continuing education and advancement opportunities at every turn, you can build a long, successful career with Mayo Clinic.

Benefits Highlights
  • Medical: Multiple plan options.
  • Dental: Delta Dental or reimbursement account for flexible coverage.
  • Vision: Affordable plan with national network.
  • Pre-Tax Savings: HSA and FSAs for eligible expenses.
  • Retirement: Competitive retirement package to secure your future.
Just as our reputation has spread beyond our Minnesota roots, so have our locations. Today, our employees are located at our three major campuses in Phoenix/Scottsdale, Arizona, Jacksonville, Florida, Rochester, Minnesota, and at Mayo Clinic Health System campuses throughout Midwestern communities, and at our international locations. Each Mayo Clinic location is a special place where our employees thrive in both their work and personal lives. Learn more about what each unique Mayo Clinic campus has to offer, and where your best fit is. 

Equal Opportunity

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, national origin, protected veteran status or disability status. Learn more about the "EOE is the Law".  Mayo Clinic participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization.

High School Diploma or GED and 2+ years of relevant experience required

OR

Bachelor's degree required
Additional Requirements include:
Ability to read and communicate effectively
Basic computer/keyboarding skills, intermediate mathematic competency
Good written and verbal communication skills
Knowledge of proper phone etiquette and phone handling skills
Position requires general knowledge of healthcare terminology and CPT-ICD10 codes. Basic knowledge of and experience in insurance verification and claim adjudication is preferred. Requires excellent verbal communication skills, and the ability to work in a complex environment with varying points of view. Must be comfortable with ambiguity, exhibit good decision making and judgment capabilities, attention to detail. Knowledge of Denial codes is preferred. Knowledge of and experience using an Epic RC/EMR system is preferred. Healthcare Financial Management Association (HFMA) Certification Preferred.

**This vacancy is not eligible for sponsorship / we will not sponsor or transfer visas for this position.  

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About Mayo Clinic

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Mayo Clinic is the largest integrated, not-for-profit medical group practice in the world. We're building the future, one where the best possible care is available to everyone — and more people can heal at home. Our relentless research turns into earlier diagnoses and new cures. That's how we inspire hope in those who need it most. At Mayo Clinic, experts work together to solve the most challenging unmet needs of patients. Our history of innovation dates back almost 150 years, when brothers Will and Charlie Mayo pioneered an integrated, team-based approach to medicine. Today, that trailblazing spirit drives innovations like Mayo Clinic Platform — which powers new technologies to change how care is delivered to all.

Industry

Hospitals

Company size

10,000+ Employees

Headquarters location

Rochester, MN, US

Year founded

1919

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