Clinical Review Nurse - Prior Authorization

Position Title:  Clinical Review Nurse - Prior Authorization
Work Location: Remote-US
Can be located anywhere in the US as long as they have a compact license
Assignment Duration: 3 Months Contract to Hire
Work Schedule: 8 am-5 pm EST, Monday through Friday

Responsibilities:

• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
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• Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
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• Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member
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• Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
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• Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
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• Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines
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• Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
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• Provides feedback on opportunities to improve the authorization review process for members

 

Candidate Requirements
Required: Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.			Preferred:
Required:  LPN  - Licensed Practical Nurse - State Licensure   required / Compact License			Preferred: RN
Years of experience required Disqualifiers Best vs. average Performance indicators	Must haves: 2 years experience with PA auth reviews Nice to haves: Previous experience with NC State Criteria/ InterQual Criteria Disqualifiers:   Performance indicators: 15 Auths reviews per day
Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection	1	Must have 2 years prior exp in PA or IP with an insurance company
	2	Must be a team player
	3	Must be willing to work an alt schedule of Monday - Friday