ZipRecruiter

Log In

2

Remote Prior Authorization Rn Jobs in Pennsylvania

The CKHobbie Group

This is a remote position. Seeking a detail-oriented and highly analytical Registered Nurse (RN) to join our team in a HEDIS Abstraction role, supporting critical healthcare quality initiatives ...

The CKHobbie Group

$42 - $47/hr

This is a remote position. We are seeking a passionate and experienced HSS Clinical Coordinator RN to join our remote care coordination team. This is a high-impact, contract-to-hire opportunity ...

next page

Showing results 1-20

All JobsPrior Authorization Rn JobsRemote Prior Authorization Rn JobsRemote Prior Authorization Rn Jobs in Pennsylvania

Remote Prior Authorization Rn information

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

AspectRemote Prior Authorization RnRemote Medical Coder
CredentialsRN license, certification in case management or utilization reviewCertification in coding (CPC, CCS), high school diploma or equivalent
Work EnvironmentHealthcare facilities, insurance companies, telehealthMedical offices, insurance companies, remote coding platforms
Industry UsageUtilization review, patient authorization, insurance approvalMedical record review, billing, coding for insurance claims

Remote Prior Authorization Rns focus on reviewing patient information to approve treatments, while Remote Medical Coders translate medical records into codes for billing. Both roles require healthcare knowledge but serve different functions within the healthcare industry.

What are popular job titles related to Remote Prior Authorization Rn jobs in Pennsylvania?

For Remote Prior Authorization Rn jobs in Pennsylvania, the most frequently searched job titles are:

What job categories do people searching Remote Prior Authorization Rn jobs in Pennsylvania look for?

The top searched job categories for Remote Prior Authorization Rn jobs in Pennsylvania are:

What cities in Pennsylvania are hiring for Remote Prior Authorization Rn jobs?

Cities in Pennsylvania with the most Remote Prior Authorization Rn job openings:

Remote Prior Authorization Rn jobs near you
Infographic showing various Remote Prior Authorization Rn job openings in Pennsylvania as of September 2026, with employment types broken down into 5% As Needed, 83% Full Time, 10% Part Time, and 2% Contract. Highlights an 2% In-person, and 98% Remote job distribution.

Pharmacy Clinical Review Specialist- Remote

Pittsburgh, PA • Remote

UPMC Health Plan
Insurance Services • 1 - 5K employees
Learn more about UPMC Health Planexternal

$122K - $142K/yr

Full-time

Medical

Posted 19 days ago

Job description

The Clinical Review Specialist will oversee administrative and system processes that relate to pharmacy prior authorizations. Manage the first line clinical review of prior authorization requests on behalf of physicians and UPMC Health Plan members. Collaborate with clinicians regarding supporting medical documentation in accordance with formulary guidelines. Manage the quality review of requested prior authorizations. Schedule is 11:30am-8:00 pm, Monday-Friday with a Saturday rotation monthly. Training schedule will be 8:30am-5:00 pm Monday-Friday. Equipment will be provided. As this position is remote, please understand that we do have the ability to have staff report to and work from our primary location, US Steel Tower as well.

Responsibilities:

  • Provide excellent internal and external customer service maintaining a second requests for information and customer complaint goal of zero.
  • Act as a conduit of information between the Pharmacy Service Representatives and the clinical staff
  • Subject matter expert on formulary exceptions and prior authorization requirements/time frames according to line of business.
  • Perform peer reviews of prior authorization requests.
  • Maintain or exceed designated quality and production standards.
  • Develop and maintain the pre-logic and clinical criteria in support of the prior authorization determination process.
  • Interface with other departments and identify medical documentation in support of prior authorization requests.
  • Complete standard/expedited pharmacy coverage determinations according to departmental/government guidelines.
  • Report and respond to escalate issues and concerns in a within twenty-four hours.
  • Process requests and inquiries in accordance with all governing regulatory agencies including but not limited to CMS, DPW, DHHS, HCFA, DOI and NCQA laws and standards.
  • HS diploma and pharmacy claims, pharmacy tech, and/or other related experience in a physician practice, ancillary provider, or other relevant healthcare setting required.
  • Competent in pharmacy claims process operating system.
  • Excellent knowledge in UPMC's Health Plan internal department functions.
  • Excellent knowledge of medical terminology, coordination of benefits, complaints and grievance guidelines and prescription drug utilization management requirements.
  • Thorough knowledge in MS Office and PC skills required.
  • Organizational, analytical, interpersonal, and communication skills.
  • Ability to prioritize and perform multiple tasks while maintaining designated production and quality standards.
  • Staff is required to work scheduled overtime and be available for emergency overtime as business needs dictate.
  • Staff is required to work a temporary, alternative schedule or shift as requested by supervisor.
    Licensure, Certifications, and Clearances:
  • Act 34


UPMC is an Equal Opportunity Employer/Disability/Veteran

Apply