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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