Job Description

• Review approximately 20 prior authorization (auth) requests daily , Monday-Friday.
• Complete all reviews and submit them to the UM Coordinator before 3:00 PM PST .
• Evaluate each auth by reviewing:
• Member's medical records
• Auth request details
• Relevant clinical criteria (CMS, Health Plan, InterQual, MCG)
• For denied or partially approved requests , provide:
• A clear, detailed rationale
• Cited criteria including name, title, and number
• Monitor your assigned auth queue in the UM system.
• Ensure that all auths are reviewed and returned within the assigned turnaround times (TAT), color-coded as:
• Red: Past due
• Yellow: Nearing deadline
• Green: Over 24 hours remaining
• Notify the team in advance for scheduled time off ; unreviewed auths must be carried over and completed the following day.
• Provide 24-hour notice for unscheduled time off , when possible.
• Collaborate with the UM team and follow protocols for criteria application and review submission.

• Training on our Prior Authorization system and workflow
• Instruction on how to cite criteria appropriately
• Criteria documents will be attached to each auth for your review

• This is a remote, part-time contract role
• Reviewers are expected to consistently meet the 20-auths-per-day quota
• Queue monitoring and daily communication with the UM team are essential for success.The pay range for this position at commencement of contract is expected to be between $6,000.00 - $6,000.00 per month.

• Active, unrestricted California medical license (MD or DO)
• Strong clinical decision-making and documentation skills
• Familiarity with CMS guidelines, InterQual, MCG, and major health plan criteria
• Ability to work independently and meet strict daily deadlines
• Comfortable working with digital systems and remote teams

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