Prior Authorization Clinical Specialist – US Registered Nurse

The Prior Authorization Clinical Specialist – US RN is responsible for providing clinical expertise and operational support in the prior authorization and utilization management process for U.S. healthcare payers. This role ensures medical necessity determinations are accurate, compliant, and timely by applying clinical judgment, payer policies, and evidence-based guidelines. The US RN serves as a key escalation point for complex authorization cases, supports appeals, and partners with internal teams and external payers to optimize authorization outcomes while maintaining regulatory compliance.

Key Responsibilities:

Prior Authorization & Utilization Review

• Conduct clinical reviews for prior authorization requests involving medical procedures, services, and medications.

• Evaluate medical necessity using payer policies, evidence-based guidelines, and clinical judgment.

Clinical Review & Docu...