Review Nurse- Prior Authorization
Job Title: Review RN- Prior Authorization
Why work at OpTech?
OpTech is a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work at OpTech, not only do you get health and dental benefits, but you also have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! To view our complete list of openings, pleas e visit our website at www.optechus.com.
Job Profile 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.
• Projected start date: 12/29/2025
• Shift hours: Tuesday- Saturday 8:30-5:00 PM CST
• 6 Month contract with extension or convert
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.
• Review Prior auth for standard, urgent, retro for IL Medicaid.
• Support UM Shared Services
• Review Prior auth for standard, urgent, retro for IL Medicaid.
• Min of 16 reviews per day
• Audit scores of 95% or greater shadowing preceptor
Qualifications
• 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
• Comply with all policies and standards
Education/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.
• License/Certification:
OpTech is an equal opportunity employer and is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, pregnancy, status as a parent, disability, age, veteran status, or other characteristics as defined by federal, state or local laws. https://www.optechus.com/eeo_self_identification/
Pay: $39.00 - $43.00 per hour
Benefits:
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance
Experience:
• Review Prior Authorization: 3 years (Required)
• Remote work environment : 3 years (Required)
• Microsoft Excel: 1 year (Required)
License/Certification:
• RN License (Required)
Work Location: Remote
Apply Now
Apply Now
Why work at OpTech?
OpTech is a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work at OpTech, not only do you get health and dental benefits, but you also have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! To view our complete list of openings, pleas e visit our website at www.optechus.com.
Job Profile 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.
• Projected start date: 12/29/2025
• Shift hours: Tuesday- Saturday 8:30-5:00 PM CST
• 6 Month contract with extension or convert
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.
• Review Prior auth for standard, urgent, retro for IL Medicaid.
• Support UM Shared Services
• Review Prior auth for standard, urgent, retro for IL Medicaid.
• Min of 16 reviews per day
• Audit scores of 95% or greater shadowing preceptor
Qualifications
• 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
• Comply with all policies and standards
Education/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.
• License/Certification:
OpTech is an equal opportunity employer and is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, pregnancy, status as a parent, disability, age, veteran status, or other characteristics as defined by federal, state or local laws. https://www.optechus.com/eeo_self_identification/
Pay: $39.00 - $43.00 per hour
Benefits:
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance
Experience:
• Review Prior Authorization: 3 years (Required)
• Remote work environment : 3 years (Required)
• Microsoft Excel: 1 year (Required)
License/Certification:
• RN License (Required)
Work Location: Remote
Apply Now
Apply Now