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Clinical Review Nurse- Prior Authorization

Spectraforce Technologies
United States, Missouri, Kansas City
April 17, 2024
Clinical Review Nurse- Prior Authorization 03 Months MO - Remote Monday - Friday 8:00 a.m. 5:00 p.m. CST Description: Prior authorization nurse is supporting a Medicaid line of business. Reviewing outpatient service requests to determine if they are medically necessary. Reviewing cases in InterQual Working with medical directors and therapists 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. Utilization management cases 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. Required Skills/Experience: 1. Utilization Management Review 2. Outpatient Medical Setting (2-3 years) 3. Comfortable with working in multiple programs Education Requirement: LPN, RN, or BSN Licensed Nurse and able to legally practice in MO Software Skills Required: Proficient in all Microsoft office programs Required Certifications: LPN, RN, or BSN Licensed Nurse and able to legally practice in MO