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TYPE OF WORK
Full Time
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SALARY
$7/hour
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HOURS PER WEEK
40
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DATE UPDATED
Aug 13, 2026
# Job Description: Clinical Medical Necessity & Prior Authorization Specialist (RN) – Remote
## Position Summary
We are seeking an experienced **Registered Nurse (RN)** with a strong background in **utilization management, medical necessity review, and prior authorizations** to join our growing interventional pain management and regenerative medicine practice. This is a fully remote position for a highly organized, analytical professional who enjoys reviewing complex medical records and ensuring that clinical documentation meets payer-specific medical necessity requirements.
The ideal candidate has previously worked for a **commercial insurance carrier, Medicare Advantage plan, utilization management company, or prior authorization department**, and understands how insurance reviewers evaluate requests for advanced procedures.
Rather than simply submitting authorizations, this role serves as a **clinical documentation consultant** by identifying gaps in documentation, cross-referencing payer policies, and helping providers optimize their notes before submission.
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# Responsibilities
* Review patient charts for medical necessity prior to submission for insurance authorization.
* Analyze large medical records (100–500+ pages) and identify relevant clinical information.
* Compare provider documentation with payer-specific medical necessity criteria.
* Identify documentation deficiencies that could result in authorization denials.
* Recommend specific additions or revisions to provider documentation to strengthen medical necessity.
* Prepare comprehensive authorization packets for submission.
* Assist with first-level and second-level appeals following denials.
* Track payer-specific documentation requirements and maintain internal authorization checklists.
* Stay current with Medicare LCDs/NCDs and commercial payer policies.
* Communicate effectively with physicians, nurse practitioners, and authorization staff regarding documentation improvements.
* Maintain detailed tracking of authorization status, denials, appeals, and outcomes.
* Assist in developing standardized documentation templates to improve approval rates.
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# Procedures Supported
Experience reviewing medical necessity for one or more of the following is strongly preferred:
* Stem Cell Procedures
* Platelet-Rich Plasma (PRP) Procedures
* Other Regenerative Medicine Procedures
* Pain Management Procedures
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# Required Qualifications
* Active Registered Nurse (RN) license
* Minimum 5 years of clinical nursing experience
* Minimum 2 years of utilization management, medical necessity review, or prior authorization experience
* Previous employment with a commercial insurance company, Medicare Advantage plan, or utilization management organization strongly preferred
* Excellent understanding of medical terminology and clinical documentation
* Exceptional attention to detail
* Strong written communication skills
* Ability to work independently while managing multiple cases simultaneously
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# Preferred Qualifications
Experience with:
* eClinicalWorks (eCW)
* InterQual Criteria
Clinical experience in one or more of the following specialties is highly desirable:
* Pain Management
* Orthopedic Surgery
* Neurosurgery
* Neurology
* Physical Medicine & Rehabilitation
* Interventional Spine
* Anesthesiology
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# Desired Skills
The successful candidate will be:
* Extremely detail-oriented
* Highly organized
* Able to synthesize large amounts of clinical information quickly
* Comfortable reading imaging reports and specialist consultation notes
* Able to identify inconsistencies within medical records
* Skilled at translating payer requirements into actionable documentation recommendations
* Professional and collaborative when working with providers
* Passionate about improving first-pass authorization approval rates
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# Performance Metrics
Success in this role will be measured by:
* First-pass authorization approval rate
* Reduction in insurance denials
* Appeal success rate
* Turnaround time for chart review
* Accuracy of medical necessity assessments
* Provider satisfaction with documentation recommendations
* Revenue protected through improved authorization outcomes
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# Compensation
Compensation is competitive and will be based on experience.
Full-time and part-time applicants will be considered.
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# Why Join Us?
Our practice specializes in advanced interventional pain management and regenerative medicine. You will work directly with physicians to improve documentation quality, increase insurance approval rates, and ensure patients receive medically necessary care without unnecessary delays.
This is an opportunity to become an integral member of a collaborative team where your expertise will directly impact patient access to care and practice success.
