Clinical Review Nurse - Prior Authorization
Clinical Review Nurse - Prior Authorization
Pacer Staffing LLC
United States
See who Pacer Staffing LLC has hired for this role
Job title: Clinical Review Nurse - Prior Authorization
Location: Fully Remote
Duration: 6+ months
Notes
Location: Fully Remote
Duration: 6+ months
Notes
- Initially the workweek would consist of weekend days can be (4) 10-hour shifts.
- Thursday, Friday, Saturday, Sunday
- Saturday, Sunday, Monday, Friday
- Looking for a candidate able / willing to work at least a half day (4) hours on Saturday– full day.
- The hours are 8am -5 pm. The schedule can be flexible.
- 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.
- Bachelor’s degree.
- 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.
- Reviewing authorization requests
- Utilizing evidence-based criteria and making a medically necessary determination.
- Outreach calls to providers to request additional details if applicable.
- They will not be completing any calls to members.
- 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.
- 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.
- ICU, Medical Surgical background, bedside experience (Home health nurses)
- Utilization Review
-
Seniority level
Entry level -
Employment type
Full-time -
Job function
Health Care Provider -
Industries
Staffing and Recruiting
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