PHRN - Clinical Admin

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

The Clinical Admin Nurse / Prior Authorization Nurse will require ability to read through clinical information, interpret guidelines and provide recommendation to the physician if medication will not meet criteria for Prior Auth before sending request to Payer. The Clinical Admin Nurse / Prior Authorization Nurse needs to communicate the decision (via phone) to members whether the drug has been approved or denied by Payers. plays a critical role in ensuring centralized, accurate, and timely submission of payer agnostic prior authorization forms and appeals through prescription benefits, thereby promoting optimal patient care coordination and cost-effective utilization of healthcare resources. They support the Kelsey-Seybold providers across all payors.

Primary Responsibilities

The Clinical Admin Nurse / Prior Authorization Nurse will perform their job functions, adhering to both Optum and Kelsey Seybold ePA policies and procedures, which include but are not limited to the following:

• Prior Authorization Processing
• Review incoming prior authorization requests from the work queue
• Collaborate with pharmacists and pharmacy technicians during case review
• Complete electronic prior authorization (ePA) submissions accurately and within defined turnaround times
• Ensure all required clinical documentation and payer-specific criteria are met before submission
• Clinical Coordination & Communication
• Respond to clinical questions related to prior authorizations or contact the prescribing provider (MD/DO) for clarification as needed
• Communicate with providers within established response timeframes (e.g., allowing up to 30 minutes for MD responses when applicable)
• Document communications thoroughly in the appropriate systems
• Payer Interaction & Follow-Up
• Monitor payer responses received electronically or via fax
• Interpret payer determinations (approval, denial, or request for additional information).
• Escalate cases appropriately when payer responses require further action or appeal review
• Approval Workflow
• Process approved ePAs by scanning and uploading documentation as required
• Coordinate release of medications or prescriptions when applicable
• Send patient notifications (e.g., messaging through patient portal or designated communication platform)
• Close completed cases from the work queue accurately
• Denials & Appeals Support
• Document denied ePAs and upload denial letters or supporting documents to SharePoint or designated repository
• Notify the prescribing provider of denial outcomes and alternative therapy options
• Coordinate with Pharmacists for appeal preparation when required
• Assist with patient communication regarding denials, out-of-pocket costs, or alternative treatments
• Patient Communication
• Contact patients by phone when required to explain prior authorization outcomes or next steps
• Send written correspondence (letters or secure messages) if patients cannot be reached by phone
• Document all patient communications according to policy
• Compliance & Documentation
• Maintain compliance with HIPAA, payer guidelines, and organizational policies
• Ensure accurate, timely, and complete documentation for all ePA activities
• Adhere to turnaround time standards and quality metrics for prior authorization processing
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so
  

• Bachelors degree holder
• Active Registered Nurse (PHRN) license (unrestricted)
• 2+ years of clinical practice experience; preferably ED, telemetry, or ICU
  
  

• Experience working with pharmacy services or specialty medications
• Experience supporting provider offices or health plans
• Clinical experience in utilization management, prior authorization, or case management
• Knowledge of medication prior authorization processes and payer requirements
• Familiarity with appeals and denial management processes
• Proficiency with electronic health records (EHR), ePA platforms, and document management systems
• Proven ability to interpret clinical documentation and apply payer medical necessity criteria
• Proven solid communication skills, both verbal and written