Clinical - Clinical Review Nurse - Prior Authorization

Location : Remote, candidate needs to be in AZ!

Shift is Monday -Friday am- pm or : am- pm, No OT

Duration : + months

Please Note : Manager is going to be very selective due to the urgent need. Ideal candidate will need to have Managed Care experience and Prior Auth!

• Requires PA experience or experience in MM or UM experience.
• Candidate should have experience in a remote role

Job Description : 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.

Education / Experience :

Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and years of related experience.

Requirements;

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.

Walk me through the day-to-day responsibilities of this the role and a description of the project :

• Review for medical necessity-based on the criteria available
• Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
• 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.
• Reviewing clinicals for procedures against the medical policies to determine medical necessity.

Describe the performance expectations / metrics for this individual and their team :

Quality and production metrics must be met to be successful.

Tell me about what their first day looks like :

Nurse will complete approx. wks of corp training and then work : with a nurse on our team.

Required Skills / Experience : Preferred Skills / Experience : . Previous PA experience and experience in MM or UM. . Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.

• Strong computer skills-ability to navigate multiple systems . Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred. Education Requirement : Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and years of related experience.

Education Preferred : Software Skills Required : Required Certifications : 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 :