Job Description

Prior Authorization Medical Clinician


Evaluates and approves requested services using organizational policies or InterQual® screening criteria. Manages appropriate cases that require medical necessity review such as home care, elective inpatient and outpatient service requests. Monitors and complies with all state, federal and regulatory requirements relative to accuracy and turnaround times and adheres to the benefit design of Massachusetts and New Hampshire products in managing all requests.


Key Functions/Responsibilities:

  • Reviews cases referred by the prior-authorization non-clinical staff according to member benefits, provider availability, and pre-determined medical necessity criteria.
  • Clearly and succinctly presents cases to ensure quality care while advocating for appropriate utilization of health system resources (e.g. site of service, level of care, length of stay, etc) consistent with health plan’s policy, criteria guidelines, and goals.
  • Clearly and succinctly documents necessary and/or required information in health plan’s UM system.
  • Uses clinical subject matter expertise as well as knowledge of the interconnection between UM, claims, and regulatory requirements to respond to complex and/or escalated inquiries.
  • Identifies members who could benefit from care management and refers to the appropriate care manager.
  • Utilizes critical thinking skills to identify process issues and problems, and recommend and/or implement solutions.
  • May identify workflow and systems improvements to enhance UM’s ability to monitor, document and improve key department performance indicators.
  • Uses clinical expertise and analytical ability to identify opportunities for new approaches to better address the needs of targeted members, improve outcomes, stakeholder satisfaction, or department effectiveness.
  • Maintains caseload volume, complies with contractual requirements regarding turnaround times, and meets department productivity standards.
  • Works collaboratively with internal constituents to understand and successfully meet the goals of the department and organization.
  • Builds effective external relationships with business partners such as providers, facilities, and vendors to support program effectiveness.
  • May be asked to represent the health plan or UM department effectively as a subject matter expert in meetings with individuals or groups.
  • Uses UM system platform with proficiency.



Education :

  • Bachelor’s Degree in Nursing or Nursing School Degree with equivalent relevant work experience.

Experience Required:

  • At least 3 years of related experience in an acute care or health insurance environment.
  • At least 2 years of experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning.

Experience Preferred/Desirable:

  • Experience in acute care and/or rehab nursing.
  • Experience with Medicaid or Medicare recipients and community services.
  • Experience with FACETS, CCMS, InterQual®, ZeOmega’s Jiva, or other healthcare database.

Required Licensure, Certification or Conditions of Employment:

  • Current unrestricted licensure as a Registered Nurse or License Practical Nurse.
  • CCM Certification preferred.

Competencies, Skills, and Attributes:

  • Bi-lingual preferred.
  • Demonstrates comfort with ambiguity and change.
  • Ability to create positive work environment and dynamic with individuals and groups.
  • Ability to take action in solving problems exhibiting sound judgement.
  • Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
  • Demonstrated strong organization and time management skills.
  • Able to work in a fast paced environment; ability to multi-task.
  • Experience with standard Microsoft Office applications, particularly MS Outlook, Word, Excel and other data entry processing applications.
  • Strong analytical and clinical problem solving skills.

Working Conditions and Physical Effort:

  • Ability to work OT during peak periods.


*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

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