Clinical - Clinical Review Nurse - Prior Authorization - J00927

Remote National (PST Time Zone).

Duration : 3 months, no possibility for extension or conversion to permanent

Shift : 8am-5pm PST with occasional weekend / holiday work with team rotating schedule.

Must possess at least 2 years of Prior Authorization experience with an insurance company.

Position Purpose :

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.

Education / Experience :

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

Responsibilities

Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria

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

Complies with all policies and standards

Candidate Requirements- LPN / RN in Nursing; Must have at least 2 years prior experience in Prior Authorization with an Insurance company Education / Certification Required : LPN / AS RN Preferred : RN Licensure Required : i.e. RN, LPN Preferred :

• Years of experience required
• Best vs. average
• Performance indicators

Must haves : 2 years experience with PA or IP auth reviews

Nice to haves : Willingness to learn

Positive attitude

Performance indicators :

Up to 20 auth reviews per day

1 Previous experience with prior auth

2 Must be a team player that works well independently 3 Must be willing to work a flexible schedule of 1 weekend a month, a few holidays per year