A day in prior authorization

A day in the shift: prior authorization.

Prior authorization is fast, structured, and clock-driven. Requests come in before care happens, and your job is to read each one against the plan's rules and route it correctly, quickly, and cleanly. Here is the rhythm of it.

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The queue

You sign in and the queue is already populated with requests, some flagged expedited. The first move is always the same: understand the timeframe you are working inside before you touch a case.

How the shift moves

  1. Open the queue and sort by clock

    Expedited requests carry the tightest deadline, so they come first. You order the queue by how much time each case has left, not by when it arrived. The clock sets the priorities for you.

  2. Read the request packet

    You read what is being requested and the clinical information attached. You are checking that the request is complete and that the documentation speaks to the plan's requirements for this service.

  3. Reconcile against the plan's rules

    You check the request against eligibility and the applicable coverage rules. If a required piece is missing, the case is not a denial - it is a pend for the specific information that would let it move.

  4. Watch the turnaround clock

    Every request has a regulated decision window. You confirm where this one sits against its deadline and make sure a pend or a route happens with time to spare. A missed clock can change the outcome on its own.

  5. Write the note and commit the disposition

    You write a short, precise note - what was requested, what you checked, and what happens next - then commit the disposition the record supports: approve within your authority, pend for a named item, or route for a coverage determination. Decisions reserved for a physician reviewer stay with the physician reviewer.

Reading the criteria

Reading criteria here means matching a request to the plan's stated rules for that service and noting exactly what is present and what is missing. It is careful comparison, not recall from memory, and it never involves reproducing any payer's proprietary guideline text.

RemoteNurse never reproduces or paraphrases any payer’s proprietary medical-necessity criteria. You practice the reading skill on original, synthetic framing - no real patient data.

An honest word on pace

The pace is brisker than concurrent review because straightforward requests move quickly, but volume never justifies skipping a step. The published benchmark puts the day in perspective:

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Prior Authorization

Turnaround Clock

A synthetic expedited request is approaching its decision deadline with one requirement still outstanding. Find it, pend for it, and record the clock - without making a coverage call.

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