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 157 applicants

See who Pacer Staffing LLC has hired for this role

Position Title: Clinical Review Nurse - Prior Authorization

Location: Remote | Candidate must live in Arizona

Duration: 6 Months

Schedule: Monday – Friday 8-5 AZ time

License

  • 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

Day-to-day Responsibilities

  • Review for medical necessity-based on the criteria available
  • Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
  • 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.
  • Reviewing clinicals for procedures against the medical policies to determine medical necessity.

Required Skills

  • Previous PA experience and experience in MM or UM.
  • Strong computer skills-ability to navigate multiple systems

Education Requirement

  • Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience.

  • Seniority level

    Entry level

  • Employment type

    Full-time

  • Job function

    Health Care Provider

  • Industries

    Staffing and Recruiting

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