Prior Authorization

As a PA SME - Nurse, you will serve as a clinical and operational resource in the prior authorization process, ensuring timely and accurate approval of healthcare services. You will be part of a team of PA SMEs, where your expertise will be instrumental in navigating complex authorization requirements, resolving authorization-related issues, coordinating with insurance companies, and optimizing the prior authorization workflow to deliver results to clients. You will assess patient clinical data to address medical necessity questions posed by payers and own the escalation process for any authorization obstacles, using your expertise to determine solutions.

Key Responsibilities:

Authorization Process Management:

• Manage the prior authorization process for medical procedures, treatments, and medications, ensuring compliance with payer requirements and clinical guidelines.

Subject Matter Expertise:

• Serve as the primary point of co...