Registered Nurse - Prior Authorization

State of Utah • Salt Lake City, UT

6d • Hybrid

About The Position

Registered Nurses in this position are responsible for clinical criteria reviews to help determine medical necessity. You will work indirectly with a variety of stakeholders, including the members. Evaluation and implementation of state rules, Medicaid policies, and CMS regulations. Key responsibilities and day to day responsibilities of this position: Clinical Review & Decision Support: Conduct comprehensive clinical reviews of prior authorization submissions against evidence-based clinical criteria. Assess medical necessity and appropriateness of requested services, medications, or equipment. Provider Communication: Manage incoming and outgoing calls to healthcare providers to discuss authorization status, request additional clinical documentation, or clarify submission details. Provide clear, professional guidance to provider offices regarding the PA process. Regulatory Compliance: Ensure all reviews and determinations strictly adhere to CMS (Centers for Medicare & Medicaid Services) regulations and other relevant governing bodies. Review and interpret State and Federal guidelines to ensure organizational policies remain in full compliance with evolving laws. Team Collaboration: Collaborate with Medical Directors, peers, and internal departments to review complex cases. Participate in team meetings to calibrate on clinical criteria application and process improvements. Documentation & Quality Assurance: Maintain meticulous records of all reviews, communications, and determinations within the tracking system. Ensure all turnaround times (TAT) are met in accordance with regulatory requirements. This position may currently be a hybrid of both in-office and remote work days. Please note, a position's eligibility for remote work is established by agency management and is subject to change at their discretion, at any time, and for any reason. Effective July 1, 2021, State of Utah Employees must either reside in Utah or be in the process of relocating to within 30 days of their start date.

Requirements

• Active Registered Nurse licensure in the state of Utah

Nice To Haves

• Proven expertise in reviewing medical criteria to determine the necessity and appropriateness of care.
• Significant experience in medical document auditing, ensuring accuracy, compliance, and clinical integrity within patient records.
• Demonstrated track record of implementing state and federal policies within a healthcare or managed care environment.
• Ability to translate complex regulatory language into actionable internal workflows.
• Subject matter expertise in EOP (Emergency Only Program) and LTAC (Long Term Acute Care) regulations and service delivery.
• Clinical or administrative experience within multiple EHR (Electronic Health Record) systems.
• Advanced operational skills in Google Workspace (Docs, Sheets, Drive) and Microsoft Office Suite (Excel, Word, Teams).
• Ability to leverage digital tools to track data, generate reports, and maintain organized documentation.

Responsibilities

• Conduct comprehensive clinical reviews of prior authorization submissions against evidence-based clinical criteria.
• Assess medical necessity and appropriateness of requested services, medications, or equipment.
• Manage incoming and outgoing calls to healthcare providers to discuss authorization status, request additional clinical documentation, or clarify submission details.
• Provide clear, professional guidance to provider offices regarding the PA process.
• Ensure all reviews and determinations strictly adhere to CMS (Centers for Medicare & Medicaid Services) regulations and other relevant governing bodies.
• Review and interpret State and Federal guidelines to ensure organizational policies remain in full compliance with evolving laws.
• Collaborate with Medical Directors, peers, and internal departments to review complex cases.
• Participate in team meetings to calibrate on clinical criteria application and process improvements.
• Maintain meticulous records of all reviews, communications, and determinations within the tracking system.
• Ensure all turnaround times (TAT) are met in accordance with regulatory requirements.

Benefits

• Job Stability: Enjoy the security and reliability of employment within a well-established organization.
• Career Growth: Develop valuable skills and gain opportunities for leadership within a large organization.
• Meaningful Work: Contribute to an important service that benefits the community and supports organizational goals.
• Supportive Work Environment: Be part of a team that values cooperation, strong work ethics, and mutual support.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level