Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Fully Remote

Assignment Duration: 3 months (Possibility to extend and/or convert to FTE)

Work Schedule: M-Fri 8AM-5PM PST time

Training Schedule: 3 weeks M-Fri 8AM-5PM PST time ON CAMERA - NO TIME OFF

Work Arrangement: Remote, Candidate can reside anywhere but MUST HAVE NV license (not a compact state)

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. May call a provider for more information but will not be in contact with members.

Background & Context:

• Prior Authorization Clinical Review Nurse
• May call a provider for more information (RFI, call or fax) but will not be in contact with members.
• Trucare and Microsoft applications

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:

• Required: Requires Graduate from an Accredited School of Nursing RN/LPN or Bachelor's degree in Nursing and 2 - 4 years of related experience.
• Required: LPN, RN, or BSN MUST HAVE NV license
• Years of experience required: 2-4 years experience in health authorizations, medical terminology/hipaa guidelines
• Disqualifiers: NA
• Additional qualities to look for:
• Top 3 must-have hard skills stack-ranked by importance
• 1 Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred/analytical and critical thinking skills/problem solving/attention to detail
• 2 Knowledge of Medicaid regulations preferred.
• 3 Knowledge of utilization management processes preferred.