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.
Position Purpose
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.
Education/Experience
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.
Day To Day Responsibilities
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.
License/Certification
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.
Required Skills/Experience
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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