Position Title: Clinical Review Nurse - Prior Authorization
Work Location: Remote
Assignment Duration: 6 months, Temp to perm
Work Arrangement: Remote (Mountain/PST)
Position Summary:
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.
Key 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
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
* Knowledge of utilization management processes preferred
* LPN - Licensed Practical Nurse - State Licensure required
* For Health Net of California: RN license required
* For Superior Health Plan: RN license required
Additional Information:
* Candidates must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship will not be considered for any visas.
* Sub-contracting is not permitted.
* Contacting a hiring leader directly about a requisition or hiring need is not permitted.
* All contractors must sign a Temporary Worker Acknowledgement during background check acceptance.
Clinical Review Nurse - Prior Authorization • Phoenix, AZ, United States
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