Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization Work Location: Remote-US Can be located anywhere in the US as long as they have a compact license Assignment Duration: 3 Months Contract to Hire Work Schedule: 8 am-5 pm EST, Monday through Friday 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 Candidate Requirements Required: Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 – 4 years of related experience. Preferred: Required: LPN - Licensed Practical Nurse - State Licensure required / Compact License Preferred: RN Years of experience required Disqualifiers Best vs. average Performance indicators Must haves: 2 years experience with PA auth reviews Nice to haves: Previous experience with NC State Criteria/ InterQual Criteria Disqualifiers: Performance indicators: 15 Auths reviews per day Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection 1 Must have 2 years prior exp in PA or IP with an insurance company 2 Must be a team player 3 Must be willing to work an alt schedule of Monday - Friday

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