Job Description

Title - Clinical Review Nurse Prior Authorization

Duration - 12 months

Shift - M/Th-Sat 7am-6pm or W-Sat 7am-6pm (Saturday a must)

Location - MST time would be preferred, but anywhere in the US other than California or New York is okay with an active LVN/LVN or RN license

Pay rate: $38-40.00/hr

Overview

Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Responsibilities

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

License/Certification:

• LPN - Licensed Practical Nurse - State Licensure required Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria

Education/Experience:

• Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 4 years of related experience.

Preferred Experience

• Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

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