Prior Authorization Nurse

In Clinical Documentation Integrity at Main Campus Lee Building Work schedule will be Full-time on the Day Shift, 8-4:30. Summary: Performs a variety of duties related to obtaining prior authorization required by insurance companies for outpatient infusions. The Prior Authorization (PA) Nurse will be responsible for ensuring all infusion prior authorizations are completed across the organization, as well as, facilitating procedure-related prior authorizations that have escalated to a peer-to-peer or clinical appeal level.

The PA Nurse will be responsible for providing the necessary supporting documentation in collaboration with a group of diverse health care providers. This individual must have strong organization skills, attention to detail and customer service skills. This individual will be expected to satisfy internal and external customer’s perceived needs.

Other information: Education BSN of ADN from an accredited school of nursing and current licensure as a registered professional nurse in the State of Alabama required. Experience Minimum 5 years of nursing experience. Minimum of 1 year of medication prior authorization experience preferred. Credentials with Equivalent Qualifications: Essential: * Registered Nurse AL Single State or any of the following equivalent qualifications below:

• Registered Nurse AL NLC Multi State
• Registered Nurse Non-AL NLC Multi State Education with Equivalent Qualifications: Essential: * Associate of Science Nursing in Nursing Experience with Equivalent Qualifications: The Clinical Documentation Integrity (CDI) department plays a key role within the Revenue Cycle by ensuring the accuracy and integrity of clinical documentation and related processes. The department encompasses several specialized areas: Inpatient and Outpatient CDI, Infusion Prior Authorizations, Medical Audit, and Medicaid Screening. Each area is staffed by experienced nurses who review medical records for various clinical and regulatory purposes. Inpatient and Outpatient CDI Nurses conduct concurrent and retrospective reviews of medical records to ensure documentation accurately reflects the patient’s clinical status, severity of illness, and treatments. Their work supports appropriate coding, reimbursement, and compliance, while also providing ongoing documentation education to physicians and clinical staff. Infusion Prior Authorization Nurses manage prior authorization requests for outpatient infusions, including those requiring peer-to-peer reviews or appeals. They collaborate closely with Billing on denials and appeals to support timely patient care and reimbursement. Medical Audit Nurses perform chart audits to ensure hospital charges are appropriate and compliant. They identify billing trends, correct discrepancies, and support hospital departments with charge integrity. Medicaid Screening Nurses focus on EPSDT and Interperiodic Screenings for patients with Medicaid coverage. Their detailed reviews ensure compliance with state and federal Medicaid regulations. Together, these teams support clinical excellence, regulatory compliance, and financial sustainability through comprehensive documentation and review processes.