Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Remote - sourced nationally. MT/AZ time zone, included

Assignment Duration: 5 Months Contract to Hire

Work Schedule: Monday - Friday (8 hours)

Work Arrangement: Remote

Position Summary:

Assist the Chief Medical Director to direct and coordinate the medical management, (REPLACED CLIENT NAME WITH "our organization" where applicable)

Key Responsibilities:

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  Reviewing authorization requests

  
  
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  Utilizing evidence-based criteria and making a medically necessary determination.

  
  
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  Outreach calls to providers to request additional details if applicable.

  
  
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  Required to verbally notify decision to our members.
  
  Qualification & Experience:

  
  
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  Internal/External Groups with which the Candidate will interface:
  Required Skills/Experience:	Experience utilizing MCG and InterQual evidence based criteria as well as CMS Guidelines ( LCA, LCD, NCD) .	Preferred Skills/ Experience:
  1.	ICU, Medical Surgical background, bedside experience (Home health nurses)	1.	Medicare experience ( Utilization Management with Medicare)
  2.	Utilization Review (Prior Authorization)	2.	CCM Certification
  3.	Acute Care	3.	ACLS Certification
  Education Requirement:	Bachelor's with RN or RN without Bachelors is okay too, LPNs are welcomed, as well	Education Preferred:
  Software Skills Required:	TruCare is the system the team uses so if they have experience it is beneficial. Microsoft Office Systems
  Required Certifications:	RN is what the team is really looking for (If the person has an RN license without a bachelors, they are okay) LPN - Licensed Practical Nurse - State Licensure required Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.	Required Testing:	n/a