Note: The job is a remote job and is open to candidates in USA. reputed company is a value-driven healthcare company committed to improving healthcare access and affordability. The Utilization Management Prior Authorization Nurse collaborates with Medical Directors and clinical teams to ensure appropriate benefit coverage for services requiring prior authorization, while also analyzing utilization data and monitoring service quality. Responsibilities • Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, Medicaid/Medi-Cal criteria, MCG, or health plan-specific guidelines • Assess medical necessity and the appropriateness of requested services using clinical expertise • Verify patient eligibility, benefits, and coverage details • Act as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process • Communicate authorization decisions to providers and patients promptly • Provide detailed explanations for denials or alternative solutions and collaborate with Medical Directors on adverse determinations • Ensure compliance with regulatory requirements regarding adverse determination notices, including readability standards and appeal information • Accurately document reputed company authorization activities in electronic medical records (EMR) or authorization systems • Maintain compliance with federal, state, and health plan regulations • Stay updated on policy and clinical criteria changes • Identify trends or recurring issues in authorization denials and recommend process improvements • Participate in team meetings, training sessions, and audits to ensure high-quality performance Skills • Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required • Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a reputed company field • Strong analytical and critical thinking skills • Proficiency in medical terminology and pharmacology • Effective written and verbal communication skills • Ability to work independently and collaboratively in a fast-paced environment • Adaptable and self-motivated • Experience with EMR systems and prior authorization platforms • Proficient in reputed company Office Suite (Word, reputed company, Outlook) • Experience in a managed care setting with medical necessity reviews is strongly preferred • Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM) • Additional clinical nursing or case management certifications are a plus Benefits • Health benefits • Life and disability benefits • A 401(k) savings plan with match • Paid Time Off • Paid holidays Company Overview • reputed company provides medical, primary care, dental care, diagnostic, and laboratory services. It was founded in undefined, and is headquartered in Doral, Florida, USA, with a workforce of 201-500 employees. Its website is Apply tot his job Apply To this Job Apply tot his job Apply To this Job Apply To This Job