[Hiring] Prior Authorization/Concurrent Review Nurse @Central Health
Role Description
This role involves working with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review, and other utilization management activities aimed at providing members with the right care at the right place at the right time.
ā¢ Provides daily review and evaluation of members that require hospitalization and/or procedures, providing prior authorizations and/or concurrent review.
ā¢ Mentors and trains new team members.
ā¢ Assesses services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.
ā¢ Utilizes clinical skills to review and monitor members' utilization of health care services.
ā¢ Performs telephonic reviews of inpatient hospital admissions and assists with the coordination of discharge planning needs.
ā¢ Obtains necessary information to assess a member's clinical condition and identify ongoing clinical care needs.
ā¢ Evaluates options and services required to meet the member's health needs in support and collaboration with disease management interventions.
ā¢ Performs prospective, concurrent, and retrospective review of inpatient, outpatient, ambulatory, and ancillary services requiring clinical review.
Hours of operation are Monday through Friday 8 am to 5 pm, including extended hours that may occur on weekends and/or holidays as required by State and Federal regulations.
This position is considered Remote, with occasional visits required to a Central Health office in Austin, Texas. Remote work is not available for residents of California, Colorado, New York, New Jersey, Hawaii, Maryland, Montana, Pennsylvania, Virginia, or Washington.
Qualifications
ā¢ High School Diploma or equivalent Required
ā¢ Completion of an accredited (RN) or an accredited (LVN) program Required
ā¢ One (1) year clinical practice experience Required
ā¢ Two (2) years managed care experience with utilization management and/or case management
Requirements
ā¢ Active, unrestricted State Registered Nursing license in good standing
Company Description
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This role involves working with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review, and other utilization management activities aimed at providing members with the right care at the right place at the right time.
ā¢ Provides daily review and evaluation of members that require hospitalization and/or procedures, providing prior authorizations and/or concurrent review.
ā¢ Mentors and trains new team members.
ā¢ Assesses services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.
ā¢ Utilizes clinical skills to review and monitor members' utilization of health care services.
ā¢ Performs telephonic reviews of inpatient hospital admissions and assists with the coordination of discharge planning needs.
ā¢ Obtains necessary information to assess a member's clinical condition and identify ongoing clinical care needs.
ā¢ Evaluates options and services required to meet the member's health needs in support and collaboration with disease management interventions.
ā¢ Performs prospective, concurrent, and retrospective review of inpatient, outpatient, ambulatory, and ancillary services requiring clinical review.
Hours of operation are Monday through Friday 8 am to 5 pm, including extended hours that may occur on weekends and/or holidays as required by State and Federal regulations.
This position is considered Remote, with occasional visits required to a Central Health office in Austin, Texas. Remote work is not available for residents of California, Colorado, New York, New Jersey, Hawaii, Maryland, Montana, Pennsylvania, Virginia, or Washington.
Qualifications
ā¢ High School Diploma or equivalent Required
ā¢ Completion of an accredited (RN) or an accredited (LVN) program Required
ā¢ One (1) year clinical practice experience Required
ā¢ Two (2) years managed care experience with utilization management and/or case management
Requirements
ā¢ Active, unrestricted State Registered Nursing license in good standing
Company Description
Apply tot his job
Apply To this Job