Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Remote (Must have a multi-state license)

Assignment Duration: 6 Months

Work Schedule: 8am - 5pm Central Time Zone

Work Arrangement: Remote

Position Summary:

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.

Background & Context:

Prior authorization nurse is supporting a Medicaid line of business.

Key Responsibilities:

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

* 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

Qualification & Experience:

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

* 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.

* LPN - Licensed Practical Nurse - State Licensure required