RN Clinical Authorization Nurse
About The Position
Ensuring Compliance. Streamlining Authorizations. Supporting Patient Care. The Clinical Authorization Nurse plays a key role in supporting our authorizations department by reviewing clinical information requirements from Medicare, Medicaid, and commercial payer policies. This position oversees authorization and eligibility processes, working closely with billing, collections, and field staff to ensure compliance and smooth claims processing. As a Clinical Authorization Nurse, You Will: Perform reviews of medical records and documentation with an emphasis on payer eligibility requirements Compile patient medical record information to meet the standards of Medicare, Medicaid, and commercial policies Partner with staff on obtaining documentation necessary for clean claim billing Manage and communicate with the team regarding the appeals process for claims Collaborate with Directors of Billing and Collections to maintain compliance with MCD/MCR, state and federal regulations, NHPCO standards, and ACHC standards Develop and maintain tracking logs and spreadsheets related to claims processing Support senior management in the development and analysis of performance metrics to ensure operations align with strategic goals Work cooperatively with field staff and leadership to address compliance and documentation needs Demonstrate strong communication skills across all levels of the organization Uphold the company’s core values and maintain confidentiality in all work
Requirements
- Registered Nurse license
- Three years of experience in home care or hospice
- Strong knowledge of payer eligibility requirements and claims processes
- Ability to handle confidential information with integrity
- Excellent organization and problem-solving skills
- Proficiency with multiple computer systems and applications
- Strong communication skills with field staff, management, and executives
- Ability to manage multiple priorities with strong attention to detail and follow-up
Nice To Haves
- Bachelor’s degree in Nursing or related field
- Experience working directly with appeals processes for Medicare, Medicaid, and commercial policies
- Familiarity with NHPCO and ACHC compliance standards
Responsibilities
- Perform reviews of medical records and documentation with an emphasis on payer eligibility requirements
- Compile patient medical record information to meet the standards of Medicare, Medicaid, and commercial policies
- Partner with staff on obtaining documentation necessary for clean claim billing
- Manage and communicate with the team regarding the appeals process for claims
- Collaborate with Directors of Billing and Collections to maintain compliance with MCD/MCR, state and federal regulations, NHPCO standards, and ACHC standards
- Develop and maintain tracking logs and spreadsheets related to claims processing
- Support senior management in the development and analysis of performance metrics to ensure operations align with strategic goals
- Work cooperatively with field staff and leadership to address compliance and documentation needs
- Demonstrate strong communication skills across all levels of the organization
- Uphold the company’s core values and maintain confidentiality in all work
Benefits
- Competitive Pay
- 401(k) with Company Match
- Career Advancement Opportunities
- National & Local Recognition Programs
- Teammate Assistance Fund
- Medical, Dental, Vision Insurance
- Mileage Reimbursement or Fleet Vehicle Program
- Generous Paid Time Off + 7 Paid Holidays
- Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care)
- Education Support & Tuition Assistance
- Free Continuing Education Units (CEUs)
- Company-paid Life & Long-Term Disability Insurance
- Voluntary Benefits (Pet, Critical Illness, Accident, LTC)
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
5,001-10,000 employees
