Clinical Review Nurse - Prior Authorization

Position Title : Clinical Review Nurse - Prior Authorization

Work Location : Remote : National (PST Time Zone).

Assignment Duration : 3 months

Work Schedule : 8am-5pm PST

• Work Mon-Fri 8a-8p PST with occasional weekend / holiday work with team rotating schedule.

Work Arrangement : Remote

Position Summary :

OR Medicaid Plans

Friendly welcoming teams, work well together but process work independently.

Increase need for staff as workload has increased.

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

Qualification & 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.

For certain plans : RN license required

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

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

Nice to haves : Willingness to learn, Positive attitude

Performance indicators : Up to 20 auth reviews per day

Top candidate review points (as ranked) : 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

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 RNPreferred : RN Licensure Required : i.e. RN, LPN Preferred :

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

1Previous experience with prior auth

2Must be a team player that works well independently3Must be willing to work a flexible schedule of 1 weekend a month, a few holidays per year

Required

Preferred

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