Clinical - Clinical Review Nurse - Prior Authorization

Immediate need for a talented Clinical Review Nurse - Prior Authorization.This is a 05+ Months Contract opportunity with long-term potential and is located in DE(Remote). Please review the job description below and contact me ASAP if you are interested.

Job ID:24-17434

Pay Range: $35 - $38/hour.  Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Note-Shift (Start/End Time): East Coast Time Zone, Monday to Friday 8:00 - 5:00 p.m., Alternating weekends Saturday or Sunday (2 hours a day on the weekend).

Key Responsibilities:

• 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.  

Key Requirements and Technology Experience: 

• Productivity of 15 decision authorizations per day.
• Sit with a current team member and shadow.
• Learn about TruCare.
• Someone will shadow the new hire on authorizations to ensure understanding.
• Prior PA experience required, InterQual, Care Guidelines, State Policy Experience.
• Prior PA experience required.
• Experience in InterQual Milliman.
• Understanding state policies
• Education Requirement: Associates
• Software Skills Required: InterQual Milliman, Microsoft Office
• Required Certifications: LPN - Licensed Practical Nurse - State Licensure required Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
• 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.

Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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