Prior Authorization Nurse

A prior authorization nurse reviews requests for medical treatments, services, or procedures to determine whether they qualify for insurance coverage. The job requires nurses to assess, evaluate, and provide recommendations to help ensure patients receive the services they need.

Remote prior authorization nursing is a great option for nurses who want to work from home without being tied to the phone all day. The job requires critical thinking and attention to detail. Many prior authorization nurses report they enjoy the structured daily schedule with clearly outlined tasks.

Prior authorization is closely related to utilization management (UM) nursing or utilization review (UR) nursing. While UR/UM nursing can occur at any point in the patient journey, prior authorization (or prospective utilization management) occurs before care or services are provided to the patient.

Learn more about whether prior authorization could be a good fit for you, including:

  • What does a prior authorization nurse do?
  • Where do prior authorization nurses work?
  • A day in the life as a prior authorization nurse
  • Background and experience for prior authorization nurses
  • Certifications for prior authorization nurses
  • Interview tips for prior authorization nurses
  • Salary ranges for prior authorization nurses
  • Pros and cons of working as a prior authorization nurse

What does a prior authorization nurse do?

A prior authorization nurse reviews requests for services, medications, procedures, and treatments to determine whether they are medically necessary and should be covered by insurance.

To make this determination, the prior authorization nurse must use their clinical nursing judgment to evaluate patient data, provider records, and diagnostic information as well as structured frameworks for making determinations.

Each recommendation must be evaluated carefully to ensure that every patient receives the care they need. Case determinations should include clear evidence to support the recommendation.

Nurses who work in prior authorization may also be called a benefits management nurse or utilization management (UM) nurse. Other terms for prior authorization include precertification, pre-authorization, prior approval, and pre-determination. 

What a remote prior authorization nurse has to say about their day…
My day starts by grabbing cases from the queue by earliest date, process following state rules and internal company guidelines, and send to MD if not RN approvable. We sometimes call provider offices for missing chart notes or labs but otherwise very little phone time. Our team utilizes Teams chats for questions, and for more in-depth concerns, we email or have a direct Teams call to the preceptor or manager. Take breaks/lunch whenever, flexible start and end time w/manager approval. 5 eight-hour shifts or 4 ten-hour shifts are available. You are fairly tied to your computer because this is a productivity-based role, so the more cases you crank out, the better you meet the company goal.
*response edited for clarity

Who hires prior authorization nurses?

You can find opportunities to work in prior authorization at many health insurance agencies and care management companies. There are also opportunities to specialize, such as NICU or pediatrics precertification.

Ready to learn more? You can find opportunities in prior authorization on the Nurse Fern job board.

What a remote prior authorization nurse has to say about their day…
I log in to my secured internet using a code from a phone-based verification application, the internet has to be hard-wired. We receive a list of how to work which order in different queues. Management communicates workflow changes through Microsoft Teams. I review each prior authorization request and make sure I have what I need to process it or have the medical documentation I need. If I don’t, I make an outbound call and request. We have people who take inbound calls for us who are techs, but if they are swamped, we have to drop everything and answer Inbound calls. We also work faxes as they come in. The job is not flexible and you must take breaks at specified times. You are locked to one place since it’s hard-wired. You have metrics to meet.
*response edited for clarity

A day in the life as a prior authorization nurse

Prior authorization nurses are typically assigned tasks through an online queue. Each day, the nurse works through the cases in their queue. If they need additional information to make a determination, they might reach out to providers or other resources over the phone or via email and messaging software.

To make determinations, the prior authorization nurse reviews patient records and medical provider notes to understand the request for services and whether it is necessary. If the case is unclear or requires more expertise, the nurse may forward it to another provider for review. 

Determinations follow clear guidelines and frameworks for decision-making, including Interqual, Medicare guidelines, or the Milliman Care Guidelines.

In addition to case reviews, some prior authorization nurses receive inbound calls from patients who have questions. There may also be team meetings, trainings, and other scheduled events.

Most prior authorization nurses work five days a week. Some are able to work four ten-hour days or even two twelve-hour shifts. 

While the job requires your full attention (i.e., you definitely need childcare), some prior authorization nurses say they have some flexibility in their schedule with manager approval and don’t need to take PTO for things like getting kids to the school bus in the morning or a doctor’s appointment, as long as they make up the hours within the week.

What a remote prior authorization nurse has to say about their day…
The bulk of my day is spent approving requests for a wide array of medical services. Some days I’m on the phone all day others I barely pick it up. I work with many of the other departments, such as contracting, case management, etc, to get patients care. Due to the workload, I’m glued to my desk most of the day. Per policy, the schedule is not flexible.
*response edited for clarity

Background and experience for prior authorization nurses

While at least one year of clinical bedside experience is useful, it’s possible to find work even if you are relatively new to the nursing field or if you have an LPN. Prior authorization has a steep learning curve at first, but most companies provide plenty of training and other resources to get new nurses up to speed.

Case management experience can be very useful if you’re interested in moving into prior authorization. If you enjoy helping patients access the care they need, but are looking for a position that doesn’t require a lot of phone time (like case management), then prior authorization could be a good fit.

What a remote prior authorization nurse has to say about their previous experience…
I had no prior authorization experience, but I was tech-savvy and had experience w/ precepting and teaching others (particularly with the EMR) and creating and implementing process improvements at my old job.
*response edited for clarity

Certification options for prior authorization nurses

The main certification option for prior authorization specialists is the Prior Authorization Certified Specialist offered by the National Board of Prior Authorization Specialists. 

The training and exam can be pricey, so it may be worth talking with your employer to see if they could reimburse all or part of the expense.

It could also be useful to have certifications related to utilization review or utilization management more broadly, including:

If you have case management experience, certifications in this area can also be helpful. This includes:

What a prior auth nurse has to say about their schedule and office setup…
My schedule is somewhat flexible, but generally speaking, they want you working during provider office hours. I need a quiet private space since I’m dealing with PHI and on the phone with providers’ offices.
*response edited for clarity

Interview tips for prior authorization nurses

If you’re interested in remote prior authorization positions, it’s helpful to highlight previous clinical experience, particularly in a specialty area like NICU nursing or oncology (if it’s relevant to the job). 

Recruiters will also be interested in pertinent skills and background, like:

  • Familiarity with medical billing or coding 
  • Certifications, particularly related to case management, utilization review/utilization management, or prior authorization specifically
  • Knowledge of utilization review criteria like Interqual or the Milliman Care Guidelines
  • Prior clinical and case management experience
  • Prior experience with remote work environments, particularly when it comes to time management or fulfilling set metrics

Be prepared to discuss your ability to stay organized, work independently, and stay on task. Recruiters will also want to know that you’re comfortable using technology and different medical software programs (or that you’re willing to learn). 

Finally, attention to detail and strong communication skills, as well as a dedication to ensuring that patients get the care they need, will help you stand out during the interview process. 

Are you looking to spruce up your resume and interview skills? Check out the Nurse Fern resume template and interview preparation guides to get ready to nail the job application process. 

How much do prior authorization earn?

According to Ziprecruiter, the average salary for a prior authorization nurse is $70,547 a year. Additional experience and responsibilities can help boost your annual salary. An informal poll of the Nurse Fern community showed that many nurses earn at least $70,000 per year, with 44% of respondents earning 80-100k+ per year.

Forms response chart. Question title: What is your salary range?. Number of responses: 11 responses.

It’s also important to factor in savings and other benefits from remote work, including increased job flexibility, no commuting, and the limited need for professional workwear.

Pros and cons of working as a prior authorization nurse

Many prior authorization nurses are happy with their career choices. Some of the benefits of this work include:

  • Flexible schedule
  • A generally low-stress workload (depending on the employer)
  • Straightforward daily tasks with clear-cut metrics
  • The ability to help patients advocate for the care they need
  • Increased productivity due to reduced distractions while working from home
  • The opportunity to learn about many different specialties and types of care

Prior authorization isn’t right for everyone, though. Some nurses say that prior authorization can be repetitive. Others dislike the need for phone time when reaching out to physicians or other providers for additional information, or if they need to receive inbound calls from patients who have questions about their claims. There’s also a big learning curve when just starting out, which can feel overwhelming at the beginning.

As with any remote position, there can also be challenges working from home, especially when balancing home and family life. Prior authorization nursing requires that you meet set metrics and productivity requirements, which usually involve monitoring and oversight. While break times can be flexible, most employers will expect you to be at your desk at set times during the day. 

Pros of prior authorization (from REMOTE PRIOR AUTH nurses)

I like the job. I’m a very organized, routine type of person and it was perfect.
I learn a lot about different specialties in outpatient care as well as insurance coverage/criteria. It’s nice to be able to work from home. I get a lot more done. I can take extended lunches or work funky hours with advance notice.
Knowing that I was able to help a patient and advocate for their needs with the health care team
Fewer distractions working remotely. Less office gossip and random people stopping at cubicles. 
Ability to work independently.
The ability to service the public in a cost-effective manner
*repsonses edited for clarity

Is prior authorization right for you?

Prior authorization is an excellent opportunity to work from home while ensuring that patients receive timely, necessary care. If you’re tech-savvy and enjoy working independently, prior authorization could be a great fit. 

Find your next opportunity in prior authorization nursing on the Nurse Fern job board. Curious about other remote nursing positions? Check out the Nurse Fern guides to denials & appeals nursing, data abstraction, and clinical documentation integrity.