Nov 23, 2020

Registered Nurse, Pre-Authorization

  • Memorial Health System
  • Decatur, IL, USA

Job Description

Reviews all DMH and DMG scheduled inpatient and outpatient procedures and outpatient diagnostic services to validate the scheduled procedure or diagnostic service has the appropriate payor authorization or meets the payor’s medical policies, there is a valid physician order, and other clinical documentation requirements are met prior to the scheduled procedure or diagnostic service.


Education and/or Other Requirements

Must be an RN or LPN with current Illinois license. Five years experience in clinical nursing is required.


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

  • Must possess good communication and interpersonal relationship skills.
  • Must be able to organize work with minimal supervision.
  • Must be able to focus attention to minute details.
  • Above average computer skills including Word, Excel and software applications required.

Environmental Factors

This position is performed within an environment of minimal exposure to irritating, unpleasant, or hazardous elements or conditions.

Physical Demands

The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of this job.

  • While performing the duties of this job, the employee is regularly required to sit and move through an office environment.

Mental Demands

  • While performing the duties of this job, the employee must be able to work under stress, adapt to changing conditions, and meet strict time guidelines.
  • Ability to adhere to strict confidentiality requirements.


Reasonable accommodations may be made to assist an otherwise qualified individual in the performance of the job. In order to meet the needs of the Company employees may be assigned other duties, in addition to or in lieu of those described above.


Essential Functions and Job Duties

  • Understands and applies payor prior-authorization requirements, and stays current with payor changes.
  • Interacts effectively with physicians and/or office staff when receiving information regarding hospital outpatient diagnostic services.
  • Provides information and assistance for Utilization Review and Patient Financial Services.
  • Primary function is to receive and coordinate pre-authorizations/RQI’s on patient accounts for all outpatient services and schedule inpatient admissions.
    • Coordinates phone calls in a positive and professional manner to meet departmental goals.
    • Prioritizes scheduled patients in accordance with managed care pre-auth requirements and medical necessity requirements.
    • Utilizes the account note function to record all telephone conversations, consultations, pertinent case specific information, and rationale for decision on cases, all reference numbers and authorization information.
    • Provides excellent customer service by adhering to quality standards and case management/confidentiality policy and procedures.
    • Communicates daily with appropriate parties for prior approval on patient accounts (case management or nurses at doctor’s offices).
    • Maintains/documents accurate record of insurance/pre-auth company information.
  • Communicates barriers or process improvement opportunities to management.
  • Assists in training new personnel or in implementing new procedures.
  • Performs other duties as assigned.