Clinical - Clinical Review Nurse - Prior Authorization - J00927

Title - Clinical Review Nurse Prior Authorization

Location : Fully Remote

Duration - 12 months | Possibility to extend and / or convert to FTE

Shift - Training 8AM-5PM 11 / 17-12 / 12 learning journey, trained with team lead 1on1 2 / 3 weeks. NO TIME OFF DURING TRAINING CAMERA ON DURING LEARNING JOURNEY

8AM-5PM their time zone, Monday-Friday, rotating weekends possible voluntary OT

Position Purpose :

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.

Responsibilities

Prior Authorization team for pa requests from non-contracted providers.

Team consists of 30-32 employees; this team consist of 3 smaller teams within it. Redirection team, clinical review team, and single case agreement team. All work closely together. This position is for the clinical review team.

Reviewing PA requests, opening your auths, reviewing for medical necessity and then determining them. Some team meetings may occur throughout the week CAMERA ON. Some phone time is required as the nurse may need to call for additional information to provider to support their review, or to inform the provider if the auth has been denied.

18-20 auths per day, that is averaged every month. Expectation is 95% productivity every month.

Education / Certification Required :

Requires Graduate from an Accredited School of Nursing RN / LPN or Bachelor's degree in Nursing and 2 4 years of related experience.

Licensure Required :

LVN / RN license MUST BE COMPACT

Years of experience required :

1+ year of authorization / prior auth nursing exp, navigating Microsoft Office with 3 screens utilizing different systems at the same time

Disqualifiers : job hopping (please state if contract role), most recent job must be in related field, illiteracy,

Additional qualities to look for :

Knowledge of Insurance Prior Authorization Processes / abide by consistent policy changes

Ability to Perform in a Fast-Paced, High-Volume Environment

Organizational Skills / multitasking skills / computer literacy / independent work /