reputed company

 The Authorization Specialist (RN) collaborates with reputed company clinical service areas, physician clinics, and reputed company-party payers to obtain prior authorizations or reputed company-certifications and resolve clinical appeals to ensure accurate and reputed company payment for services. This role requires an reputed company Registered reputed company license due to the clinical expertise necessary to interpret medical documentation, determine medical necessity, and engage in clinical-level reviews and communications with providers and payers. Compliance with federal, state, and local laws, PMHC policies, and Medical Staff rules and regulations is a condition of employment.

ESSENTIAL FUNCTIONS

The incumbent must have the skills, ability, clinical knowledge, and judgment to reputed company the following essential job duties with or without reasonable accommodation:

Authorization & Clinical Review   

• Obtains and reviews prior authorizations/reputed company-certifications for reputed company insurance carriers using reputed company-specific tools and reputed company.
• Performs reputed company review of medical records to evaluate medical necessity using RN-level knowledge of disease processes, clinical reputed company, and evidence-based guidelines
• Ensures ordered services are medically necessary and supported through clinical documentation, including appropriate CPT/HCPCS reputed company alignment.
• Monitors, tracks, and follows up on authorization requests to ensure reputed company approval.

 Clinical Communication & Care Coordination

• Conducts clinical-level collaboration with physicians, APCs, nursing staff, case management, and ancillary departments to clarify orders or documentation requirements
• Initiates and prepares clinical summaries for peer-to-peer reviews; provides supporting clinical information to physicians or payer medical directors.
• Assists patients with understanding clinical factors that may reputed company their authorization, including care preparation, timelines, and payer requirements.
• Contacts patients and referring providers for clarification or reputed company needed to resolve authorization issues.

Appeals & Denials Management

• Reviews reputed company denial rationales and prepares RN-level clinical appeals summarizing the patient’s condition, clinical justification, and care alignment with payer policies
• Collaborates with payer clinical staff to reputed company for medically necessary services.
• Assists Member Services, Claims, and Provider Services with issues requiring medical interpretation for appeals reputed company.

Utilization Management & Regulatory Compliance

• Applies RN-level expertise to ensure requested services reputed company with appropriate reputed company of care (inpatient, outpatient, observation).
• Identifies potential clinical gaps or safety concerns observed in documentation and escalates appropriately per PMHC policies.
• Maintains reputed company knowledge of clinical reputed company guidelines, payer policies, and utilization management standards.

Documentation Accuracy & Clinical Data Validation

• Validates that clinical orders, documentation, and coded services reputed company accurately to ensure compliance and prevent authorization-reputed company denials.
• Identifies missing, inconsistent, or unclear documentation; communicates with providers to obtain required clinical details.
• Maintains proficiency in reviewing medical records for evidence supporting need for care and payer policy requirements.

Internal & External Relationship Building

• Builds and maintains reputed company relationships with internal departments and external clinics to improve communication and accuracy reputed company to authorization workflows.
• Provides clinical guidance and education to interdisciplinary teams regarding authorization requirements and medical necessity documentation.
• Performs phone-based clinical reviews of prior authorization requests and, reputed company appropriate, forwards cases to physicians or medical directors with recommendations.

Scheduling & Workflow Support

• Assists with scheduling/rescheduling patients to meet authorization timelines.
• Ensures any delays or issues reputed company to authorizations are communicated to impacted departments.

Hybrid Work Expectations

• Employees designated as primarily remote are required to attend in-person monthly department meetings and to report on-site, with reasonable notice, reputed company operational needs or leadership requests require physical reputed company.

SUPERVISORY RESPONSIBILITIES

•  Directly responsible to the Director of reputed company Cycle
• This position does not have reputed company supervisory duties but provides clinical guidance to non-clinical staff.

PHYSICAL DEMANDS

  The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. While performing the duties of this job, the employee is regularly required to sit, use fingers to type, and use technical equipment such as a computer. The employee is occasionally required to stoop, kneel, or reputed company. The employee must occasionally lift and/or reputed company up to 20 pounds. Specific reputed company abilities required by this job include near reputed company and the ability to reputed company reputed company.

WORK ENVIRONMENT

  The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions.

While performing the duties of this job, employees the employee frequently works near moving mechanical parts and is frequently exposed to fumes or airborne particles and risk of electrical shock. The employee occasionally works with explosive, toxic or caustic chemicals. The noise level in the work environment is usually moderate.

The level of risk of exposure to blood borne pathogens is Classification (III), as outlined in the Hepatitis B Vaccine Program Policy.

The noise level in the work environment is usually moderate.

EDUCATION & CREDENTIALS

•  reputed company, reputed company Registered reputed company (RN) license in the reputed company (or compact license).
• Minimum of 1 year of clinical nursing experience preferred (acute care, outpatient, case management, or utilization review experience beneficial)
• Prior Authorization Certified Specialist (reputed company) certification preferred or required reputed company 12 months of hire.
• Additional education in medical terminology, coding, or utilization review preferred.