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Clinical Review Nurse - Prior Authorization

Clinical Review Nurse - Prior Authorization

Spectraforce TechnologiesLos Angeles, CA, United States
29 days ago
Job type
  • Full-time
Job description

Position Title : Clinical Review Nurse - Prior Authorization

Work Location : California (Remote)

Assignment Duration : 12 months (Possibility to convert )

Work Schedule : Training 8-5PM PST - 4-6 week course - NO TIME OFF - CAMERA ON 8-5PM PST.

NO OT, Holidays or weekends

Work Arrangement : Remote

Position Summary :

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

Background & Context :

  • Diverse, supporting team. Key projects for turn around time
  • Weekly overview team meetings CAMERA ON (professional environment and attire)
  • Monthly 1on1 meet CAMERA ON
  • Group chat on teams for any questions

Key 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
  • Complies with all policies and standards
  • Required to review and process PA for all LOB for . Which includes processing letters

    • Qualification & Experience :

  • Required : Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.
  • Required : RN CA licensure required
  • Years of experience required : 2-3 years of clinical experience. UM a plus,
  • 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.
  • Disqualifiers : Not having a CA RN license, No long pauses in recent work history,
  • Additional qualities to look for :
  • 1 Critical thinking / Independent work
  • 2 Organization / multitasking skills
  • 3 Microsoft Office Suite product knowledge (Teams, one note, excel and word) / tech savvy

    • Candidate Requirements

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

    Preferred :

    Required : RN CA licensure required

    Preferred :

    Years of experience required : 2-3 years of clinical experience. UM a plus,

    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.

    Disqualifiers : Not having a CA RN license, No long pauses in recent work history,

    Additional qualities to look for :

  • Top 3 must-have hard skills stack-ranked by importance

    • Critical thinking / Independent work

    Organization / multitasking skills

    Microsoft Office Suite product knowledge (Teams, one note, excel and word) / tech savvy

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    Prior Authorization • Los Angeles, CA, United States