SUMMARY

The

Authorization Specialist (RN)

collaborates with all clinical service areas, physician clinics, and third-party payers to obtain prior authorizations or pre-certifications and resolve clinical appeals to ensure accurate and timely payment for services. This role requires an active Registered Nurse license due to the clinical expertise necessary to interpret medical documentation, determine medical necessity, and engage in clinical-level reviews and communications with providers and payers. Compliance with federal, state, and local laws, PMHC policies, and Medical Staff rules and regulations is a condition of employment.

ESSENTIAL FUNCTIONS

The incumbent must have the skills, ability, clinical knowledge, and judgment to perform the following essential job duties with or without reasonable accommodation:

Authorization & Clinical Review

• Obtains and reviews prior authorizations/pre-certifications for all insurance carriers using carrier-specific tools and methods.
• Performs advanced clinical review of medical records to evaluate medical necessity using RN-level knowledge of disease processes, clinical pathways, and evidence-based guidelines
• Ensures ordered services are medically necessary and supported through clinical documentation, including appropriate CPT/HCPCS code alignment.
• Monitors, tracks, and follows up on authorization requests to ensure timely approval.

Clinical Communication & Care Coordination

• Conducts clinical-level collaboration with physicians, APCs, nursing staff, case management, and ancillary departments to clarify orders or documentation requirements
• Initiates and prepares clinical summaries for peer-to-peer reviews; provides supporting clinical information to physicians or payer medical directors.
• Assists patients with understanding clinical factors that may affect their authorization, including care preparation, timelines, and payer requirements.
• Contacts patients and referring providers for clarification or action needed to resolve authorization issues.

Appeals & Denials Management

• Reviews complex denial rationales and prepares RN-level clinical appeals summarizing the patient’s condition, clinical justification, and care alignment with payer policies
• Collaborates with payer clinical staff to advocate for medically necessary services.
• Assists Member Services, Claims, and Provider Services with issues requiring medical interpretation for appeals resolution.

Utilization Management & Regulatory Compliance

• Applies RN-level expertise to ensure requested services align with appropriate levels of care (inpatient, outpatient, observation).
• Identifies potential clinical gaps or safety concerns observed in documentation and escalates appropriately per PMHC policies.
• Maintains current knowledge of clinical practice guidelines, payer policies, and utilization management standards.

Documentation Accuracy & Clinical Data Validation

• Validates that clinical orders, documentation, and coded services align accurately to ensure compliance and prevent authorization-related denials.
• Identifies missing, inconsistent, or unclear documentation; communicates with providers to obtain required clinical details.
• Maintains proficiency in reviewing medical records for evidence supporting need for care and payer policy requirements.

Internal & External Relationship Building

• Builds and maintains collaborative relationships with internal departments and external clinics to improve communication and accuracy related to authorization workflows.
• Provides clinical guidance and education to interdisciplinary teams regarding authorization requirements and medical necessity documentation.
• Performs phone-based clinical reviews of prior authorization requests and, when appropriate, forwards cases to physicians or medical directors with recommendations.

Scheduling & Workflow Support

• Assists with scheduling/rescheduling patients to meet authorization timelines.
• Ensures any delays or issues related to authorizations are communicated to impacted departments.

Hybrid Work Expectations

• Employees designated as primarily remote are required to attend in-person monthly department meetings and to report on-site, with reasonable notice, when operational needs or leadership requests require physical presence.

SUPERVISORY RESPONSIBILITIES

• * This position does not have direct supervisory duties but provides clinical guidance to non-clinical staff.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the