Pacer Staffing LLC

Clinical Review Nurse - Prior Authorization

Pacer Staffing LLC United States
Pacer Staffing LLC

Clinical Review Nurse - Prior Authorization

Pacer Staffing LLC United States
2 weeks ago 196 applicants

See who Pacer Staffing LLC has hired for this role

Job Description

Job Title: Clinical Review Nurse - Prior Authorization

Location: Remote

Duration: 12 months (Possible Extension)

Shift Timing: Monday – Friday 8:00AM – 5:00PM

Job Summary

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.

Walk me through the day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD):

  • Behavioral Health and Psychiatric Exp required!
  • Reading treatment plans and making determinations
  • Must have experience with all ages (pediatrics to geriatrics)
  • Coordinate with providers via email and phone
  • Experience as a Review Nurse (remotely)
  • Experience with Prior auth
  • Would accept an RN with Behavioral/Mental and Psychiatric health experience or would accept a Licensed Social Worker/Licensed Professional Counselor
  • Navigating multiple systems
  • Reviewing Medical Records

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

  • Registered Nuse or Social Worker/ Counselor Requires a master’s degree and AZ license
  • Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria

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
  • Complies with all policies and standards

  • Seniority level

    Entry level

  • Employment type

    Contract

  • Job function

    Health Care Provider

  • Industries

    Staffing and Recruiting

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