Responsibilities

• Analyze prior authorization requests to determine medical necessity and appropriate level of care in accordance with national standards and member benefit coverage.
• Perform medical necessity assessments and clinical reviews of authorization requests following regulatory guidelines.
• Collaborate with healthcare providers and authorization teams to ensure timely review of services and requests.
• Coordinate with interdepartmental teams and healthcare providers to assess and confirm medical necessity.
• Escalate complex prior authorization requests to Medical Directors as needed.
• Provide recommendations to the medical team to enhance the quality and cost-effectiveness of medical care.

Requirements

• Current Registered Nurse (RN) license in California.
• Experience in clinical review, medical management, or healthcare-related roles is preferred.
• Strong understanding of medical necessity criteria and regulatory guidelines.
• Excellent communication and interpersonal skills to work effectively with healthcare professionals and teams.
• Ability to analyze complex medical information and make informed decisions.
• Proficient with computer systems and healthcare software.
• Must be able to work Pacific Standard Time (PST) hours.

Benefits

• Competitive salary and comprehensive benefits package.
• Flexible work environment with remote work options.
• Opportunities for professional growth and development.
• Supportive team culture and collaborative work environment.
• Health, dental, and vision insurance.
• Retirement savings plan with company match.