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Prior Authorization Nurse

Posted: July 09, 2024
Salary:US$36 - US$38 per hour
Location:Kansas City
Job type: Contract
Discipline:Care Management
Work Location:Remote

Job description

Medix is currently hiring a RN Prior Authorization Nurse for a Health Plan in Missouri. This position is a Monday - Friday (8a-5p) Central Time Zone. The candidate must have previous Prior Authorization experience from a Health Plan in order to be considered. See below for more details. This position is fully remote.

Job Overview

Utilizes a collaborative review process of benefits, minimally necessary clinical information and evidence-based clinical guidelines to formulate decisions regarding medical necessity, pre-existing conditions, benefits and/or individual consideration reimbursement allowables using varied and broad clinical expertise. Acts as a member and provider advocate promoting and coordinating delivery of quality, cost effective healthcare services based on medical necessity and contractual benefits


  • Conducts pre-service, concurrent and / or post-service utilization management reviews to ensure appropriate use of the health care system and to maximize health care dollars.
  • Ensures that reviews and determinations meet requirements with applicable URAC and NCQA guidelines as well as federal and state mandates
  • Reviews provider and/or member submitted medical information to determine pre-existing, medical necessity, benefits & eligibility, and/or reimbursement of a requested service, product or procedure utilizing professional knowledge, medical literature, medical records, certificate guidelines, medical policy, approved clinical guidelines
  • Refers cases that do not meet criteria to the Medical Director with an appropriate clinical analysis, summaries and recommendations
  • Contributes in the discharge planning of members to appropriate acute, SNF, in-patient hospice or rehab facilities or discharge to home with a safe plan


  • RN license (compact)
  • 3+ years full-time direct patient care clinical experience in medical/surgical, pediatrics, and/or obstetrics.
  • 1+ year(s) of utilization review, disease management, and/or case management experience.
  • Knowledge of URAC and NCQA guidelines and state and federal regulations