Nurse RN 5

This is a production-oriented clinical review role requiring strong clinical judgment, computer proficiency, and the ability to work independently in a fast-paced environment. The selected candidate will review medical authorization requests, assess medical necessity, and apply established clinical guidelines and organizational policies to support timely and accurate authorization decisions.

Position Overview

• We are seeking a qualified Registered Nurse (RN) to join the Federal Employee Program (FEP) Utilization Management Prior Authorization team. The selected candidate will review medical authorization requests, assess medical necessity, and apply established clinical guidelines and organizational policies to support timely and accurate authorization decisions.
• This is a production-oriented clinical review role requiring strong clinical judgment, computer proficiency, and the ability to work independently in a fast-paced environment.

 
Key Responsibilities

• Review and process medical prior authorization requests using the organization's authorization system.
• Complete a minimum target of 15 authorization decisions per day, with the potential for higher productivity expectations.
• Evaluate medical records and clinical documentation to determine medical necessity.
• Apply established medical policies and evidence-based clinical review guidelines.
• Review authorization requests involving diagnostic imaging, surgical procedures, genetic testing, and other medical services.
• Conduct clinical reviews to assess whether requested services meet applicable authorization criteria.
• Apply utilization management and clinical review principles to support appropriate care decisions.
• Navigate Windows-based authorization systems and electronic clinical documentation efficiently.
• Meet productivity targets, turnaround times, and established review procedures.
• Adapt quickly to focused, case-specific training and progressively handle additional categories of authorization requests.

 
Required Qualifications

• Active Registered Nurse (RN) license valid in California.
• Must currently reside in California.
• Relevant clinical nursing experience with strong assessment and clinical decision-making skills.
• Strong computer literacy and ability to work independently in a Windows-based environment.
• Ability to review clinical documentation, interpret medical information, and apply established policies.
• Strong organizational skills and ability to meet daily productivity expectations.

 
Preferred Qualifications

• Experience in Prior Authorization, Utilization Management (UM), or Utilization Review (UR).
• Health plan, payer, managed care, or health insurance experience.
• Experience with post-service or retrospective clinical reviews.
• Hospital-based concurrent review or continued-stay review experience.
• Discharge planning and care coordination experience.
• Inpatient clinical experience, particularly Medical-Surgical, ICU, acute care, or surgical nursing.
• Familiarity with MCG (Milliman Care Guidelines), InterQual, or other evidence-based clinical review criteria.
• Experience reviewing medical necessity and clinical documentation.