A Prior Authorization Nurse provides a timely review of authorisation requests and ensures the requests meet the national standard and contractual requirements. Daily responsibilities are often listed on the Prior Authorization Nurse Resume as – performing clinical reviews of authorisation requests using appropriate criteria, providing accurate and complete documentation with the rationale used to approve requests, collaborating with staff within provider networks and case management team coordinate patient care, equipping and training prior authorisation tech with needed resources, and maintaining clinical information in multiple health management systems.
Skills and abilities often considered crucial for completing the job include – knowledge of utilisation management and case management principles; knowledge of MS Word, strong service orientation and professionalism, and a driver to work well with a team. A bachelor’s degree in nursing and state licensure as a Registered Nurse is vital for this role.
Objective : Compassionate Prior Authorization Nurse with two years of experience in reviewing and processing authorization requests. Skilled in ensuring compliance with clinical guidelines and enhancing patient care through thorough documentation and collaboration with healthcare professionals. Committed to optimizing healthcare access and improving patient outcomes through effective communication and problem-solving.
Skills : Clinical Assessment, Patient Advocacy, Insurance Knowledge, Medical Terminology
Description :
Reviewed authorization requests against InterQual criteria and CMS guidelines to ensure medical necessity.
Performed accurate data entry of requests and tracked documentation in CCMS and Macess systems.
Documented medical necessity for services with precision, enhancing patient care outcomes.
Initiated referrals to Care Coordination Nurse Practitioners, MSWs, and RNs as needed.
Maintained regular communication with Medical Management to resolve outstanding authorization requests.
Assisted in addressing issues to provide members with timely and appropriate care.
Collaborated with Health Services staff to ensure efficient entry of requests into CCMS.
Experience
0-2 Years
Level
Entry Level
Education
BSN
Junior Prior Authorization Specialist Resume
Objective : Dedicated Junior Prior Authorization Specialist with 5 years of experience in evaluating and processing authorization requests. Proficient in interpreting clinical guidelines and ensuring compliance to enhance patient access to necessary services. Passionate about improving healthcare outcomes through meticulous documentation, effective communication, and collaboration with healthcare teams.
Skills : Advanced Cardiac Life Support, Basic Life Support, Cardiopulmonary Resuscitation, Telehealth Proficiency, Team Collaboration
Description :
Reviewed prior authorization requests for medical procedures, ensuring compliance with Medicare guidelines and clinical documentation.
Processed requests within required time frames according to CMS standards.
Documented authorizations and denials in the EZ-Cap database, managing grievance and appeal cases effectively.
Collaborated with medical directors for cases requiring further review or peer consultation.
Coordinated patient care with interdisciplinary teams to facilitate seamless service delivery.
Communicated with providers and members to gather necessary information and relay decisions.
Assisted in authorizations for home health services and durable medical equipment for patient discharges.
Experience
2-5 Years
Level
Junior
Education
BSN
Prior Authorization Nurse Resume
Headline : Experienced Prior Authorization Nurse with 7 years in processing and reviewing authorization requests. Adept at applying clinical guidelines and collaborating with healthcare teams to enhance patient access to essential services. Dedicated to improving healthcare outcomes through meticulous documentation and effective communication strategies.
Processed prior authorization requests for MDwise Select Health, applying Interqual criteria to assess medical necessity.
Collaborated with the medical director to facilitate timely approval or denial of medical reviews.
Resolved payment issues by liaising with MDwise regarding rejected claims.
Built strong relationships with healthcare providers to enhance client care and communication.
Maintained comprehensive knowledge of MDwise policies and IAC regulations.
Supported case managers with authorization inquiries and process-related questions.
Utilized CPT coding and ICD-9 knowledge to ensure accurate claims processing.
Experience
5-7 Years
Level
Senior
Education
BSN
Lead Prior Authorization Nurse Resume
Summary : Seasoned Lead Prior Authorization Nurse with 10 years of experience in managing authorization processes and ensuring compliance with clinical guidelines. Expert in enhancing patient access to necessary services through effective communication, detailed documentation, and collaboration with multidisciplinary teams. Devoted to optimizing healthcare quality and patient outcomes.
Managed prior authorization for complex surgical procedures, ensuring compliance with clinical standards.
Review and process prior authorization requests for medical services and procedures.
Supervised a team of authorization coordinators, facilitating effective communication among staff and providers.
Documented and resolved member inquiries and concerns promptly.
Created and updated operational policies to enhance workflow efficiency.
Developed specialized programs for chronic conditions, improving patient care outcomes.
Conducted thorough prior authorization reviews based on Interqual Criteria and Medicaid Guidelines.
Experience
7-10 Years
Level
Management
Education
BSN
Prior Authorization Nurse Resume
Summary : Driven Prior Authorization Nurse with a decade of experience in evaluating and processing authorization requests. Proficient in navigating complex clinical guidelines and collaborating with healthcare teams to ensure timely patient access to critical services. Passionate about enhancing healthcare delivery through effective communication, comprehensive documentation, and a commitment to patient-centered care.
Skills : Bilingual In English And Spanish, Strong Organizational And Communication Skills, In-depth Knowledge Of Utilization Review, Healthcare Regulations, Medical Necessity, Referral Management
Description :
Conducted comprehensive reviews of medical documentation for Medicare HMO members to assess the necessity of requested services.
Utilized Interqual and CMS guidelines, applying nursing judgment to finalize authorization approvals.
Ensured accurate coding on requests to confirm the appropriateness of procedures for each member.
Performed prior authorization and retrospective reviews in accordance with Medicare standards to evaluate medication appropriateness.
Strictly adhered to HIPAA regulations and confidentiality agreements to protect patient information.
Collaborated with treatment teams, analyzing medical records against established guidelines and benefit plans.
Maintained thorough knowledge of provider contracts and authorization requirements to facilitate effective processing.
Experience
10+ Years
Level
Executive
Education
BSN
Associate Prior Authorization Nurse
Resume
Objective : Compassionate and detail-oriented Prior Authorization Nurse with over 5 years of experience in managing patient care and insurance processes. Proficient in evaluating medical necessity, coordinating with healthcare providers, and ensuring compliance with insurance policies. Strong communication skills and a commitment to patient advocacy, aiming to streamline authorization processes and enhance patient outcomes.
Skills : Resource Management, Care Coordination, Documentation Skills, Critical Thinking
Description :
Maintain accurate records of authorization requests and outcomes.
Managed professional communications with DME and Home Health providers.
Conducted thorough medical record reviews for authorization requests.
Processed prior authorizations for Medicare and Medicaid patients.
Performed concurrent reviews for psychiatric populations to ensure appropriate care.
Facilitated Care Management and Discharge Planning for geriatric patients.
Provided training and support to staff on prior authorization processes.
Experience
2-5 Years
Level
Freelancer
Education
BSN
Prior Authorization Nurse Resume
Objective : Proactive Prior Authorization Nurse with two years of experience in evaluating authorization requests and ensuring compliance with clinical protocols. Strong ability to enhance patient access to care by effectively collaborating with healthcare teams and documenting clinical necessities. Focused on streamlining approval processes to improve patient outcomes.
Skills : Medication Management, Patient Safety, Patient Care Standards, Nursing Protocols, Electronic Health Records, Telehealth Services
Description :
Supported healthcare providers in securing prior authorizations for procedures, surgeries, and outpatient services, utilizing InterQual criteria for decision-making.
Delivered exceptional customer service while adhering to volume deadlines and ensuring timely processing of requests.
Coordinated with providers to communicate appropriate ICD-10 codes for procedures, ensuring accuracy in documentation.
Evaluated the necessity of prescribed medications to ensure compliance with clinical guidelines.
Engaged with physicians to recommend alternative treatments when necessary, prioritizing patient safety and efficacy.
Rendered authorizations and denials based on thorough review of clinical documentation and medical necessity.
Collaborated with Medical Directors on complex cases to ensure optimal patient outcomes.
Experience
0-2 Years
Level
Junior
Education
BSN
Outpatient Prior Authorization Nurse Resume
Headline : Dedicated Prior Authorization Nurse with extensive experience in reviewing and processing prior authorization requests. Skilled in collaborating with healthcare teams and insurance companies to ensure timely approvals. Adept at utilizing clinical knowledge to assess treatment plans and advocate for patients. Committed to improving healthcare access and efficiency while maintaining high standards of patient care.
Skills : Communication Skills, Interpersonal Skills, Problem Solving, Attention To Detail, Data Entry, Regulatory Compliance
Description :
Evaluated and processed authorization requests in accordance with clinical guidelines and departmental policies.
Collaborated with healthcare providers to obtain necessary information for authorization approvals.
Documented all authorization activities accurately to ensure compliance and facilitate audits.
Identified and addressed complex cases, referring them to the Medical Director when necessary.
Monitored turnaround times for authorization requests, ensuring timely responses to providers.
Conducted follow-ups on denials and cancellations to assess quality of care.
Maintained up-to-date knowledge of URAC and Medicare policies to ensure compliance.
Experience
5-7 Years
Level
Senior
Education
BSN
Prior Authorization Nurse Resume
Summary : Dedicated Prior Authorization Nurse with extensive experience in reviewing and processing insurance authorizations. Skilled in collaborating with healthcare teams to assess patient needs and ensure timely approvals. Adept at navigating complex insurance systems and regulations, with a focus on improving patient access to necessary treatments while maintaining compliance and quality standards.
Skills : Healthcare Policy Analysis, Cultural Competence, Clinical Guidelines, Health Insurance Portability, Case Management, Quality Assurance
Description :
Managed the complete authorization process, ensuring compliance with health plan protocols.
Reviewed clinical documentation and authorization requests for accuracy and completeness.
Collaborated with healthcare providers to facilitate timely patient care and referrals.
Maintained detailed records of all authorization activities and patient interactions.
Trained team members on best practices in authorization processing and documentation.
Utilized electronic health records to track and document patient information effectively.
Provided exceptional customer service to patients and providers, addressing inquiries and concerns promptly.
Experience
7-10 Years
Level
Management
Education
BSN
Prior Authorization Nurse Resume
Objective : Dynamic Prior Authorization Nurse with 5 years of experience in managing authorization requests and ensuring compliance with healthcare regulations. Expertise in evaluating medical necessity and collaborating with multidisciplinary teams to enhance patient access to vital services. Driven to streamline processes and improve patient outcomes through effective communication and thorough documentation.
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