Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Remote - West Coast (CA, WA, or OR)- PST

Assignment Duration: 3 months (Potential for extension/conversion)

Work Schedule: Monday-Sunday 6 am-2 pm or 8 am-5 pm PST (weekday day off cannot be Fri or Mon) Department does need individuals to work at least 1 weekend day per week.

Note: On resume, what shift works best, 6 am-2 pm or 8 am-5 pm, and which days they are available.

Position Summary:

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  Provider facing. Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements.

  
  
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  Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

  
  

Key Responsibilities:

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  Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria

  
  
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  Works with healthcare providers and authorization team to ensure timely review of services - Reviewing requests about the member and working with providers

  
  
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  Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member

  
  
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  Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care

  
  
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  Assists with service authorization requests for a member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities

  
  
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  Collects, documents, and maintains all member's clinical information in health management systems to ensure compliance with regulatory guidelines

  
  
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  Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members

  
  
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  Provides feedback on opportunities to improve the authorization review process for members

  
  
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  Performs other duties as assigned

  
  
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  Complies with all policies and standards

  
  

Qualification & Experience:

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  Required: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.

  
  
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  Required: RN or LPN

  
  
• Preferred: Prior auth experience, clinical knowledge, Medicare/Medicaid knowledge, utilization management processes