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:

• 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.

?Background & Context:

• 
  

  OR Medicaid Plans

  
  
• 
  

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

  
  
• 
  

  Increase need for staff as workload has increased.

  
  
• Needs to have willingness to learn, positive attitude, prior auth experience preferred but not exclusionary

?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.

?License/Certification: LPN - Licensed Practical Nurse - State Licensure required

• 
  

  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