Prior Authorization RN

LSMA Management Inc • San Bernardino, CA

4h

About The Position

The Prior Authorization Registered Nurse is responsible for performing clinical review, analysis, and evaluation of authorization requests to determine medical necessity, appropriate utilization, and compliance with health plan and regulatory standards. The RN conducts prospective concurrent, and retrospective review of medical services including specialty care, diagnostic procedures, post-acute services, elective admissions, and out-of-network referrals.
The Prior Authorization RN applies advanced clinical judgment, utilizes standardized criteria sets (MCG, InterQual, CMS guidelines), and collaborates with providers, health plans, and internal clinical teams to facilitate timely, safe, and appropriate care coordination. The RN serves as a clinical resource for Prior Authorization Coordinators and supports the organization’s Utilization Management goals, quality standards, and regulatory compliance.

Requirements

• Graduate of an accredited Registered Nursing program.
• 2+ years of clinical experience in an acute or ambulatory care setting.
• Knowledge of medical terminology, clinical documentation, and care delivery systems.
• Current State Registered Nursing License
• Strong knowledge of utilization management principles, medical necessity criteria, and managed care processes.
• Proficiency in interpreting clinical documentation and applying evidence-based review criteria.
• Strong verbal and written communications skills, with ability to communicate effectively with physicians and interdisciplinary teams.
• Excellent organizational, time-management, and prioritization skills.
• Ability to maintain professionalism, confidentiality, and sound clinical judgment.

Nice To Haves

• Bachelor’s degree in Nursing or related field.
• 1+ years of experience in Utilization Management, Prior Authorization, Case Management, or Managed Care.
• Experience with MCG, InterQual, or similar criteria-based tools.
• Experience in MSO, IPA, ACO, medical group, or health plan environments.
• Working knowledge of CPT, HCPCS, and ICD-10 coding.
• Experience with EMR and UM systems.
• Certified Case Manager (CCM), Accredited Case Manager (ACM), or UM-related certifications.

Responsibilities

• performing clinical review, analysis, and evaluation of authorization requests to determine medical necessity, appropriate utilization, and compliance with health plan and regulatory standards
• conducting prospective concurrent, and retrospective review of medical services including specialty care, diagnostic procedures, post-acute services, elective admissions, and out-of-network referrals
• applying advanced clinical judgment, utilizes standardized criteria sets (MCG, InterQual, CMS guidelines), and collaborates with providers, health plans, and internal clinical teams to facilitate timely, safe, and appropriate care coordination
• serving as a clinical resource for Prior Authorization Coordinators
• supporting the organization’s Utilization Management goals, quality standards, and regulatory compliance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree