Clinical Review Nurse - Prior Authorization

Title: Clinical Review Nurse - Prior Authorization

Duration: 06 Months (Possible extension or conversion FTE)

Location: Remote (AZ)

Shift is Monday - Friday 8-5:00 or 8:30-5

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

• 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/Experience: Preferred Skills/ Experience:

• Previous PA experience and experience in MM or UM. 1. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
• Strong computer skills-ability to navigate multiple systems 2. Knowledge of Medicare and Medicaid regulations preferred.
• 3. Knowledge of utilization management processes preferred.
  
  

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

Software Skills Required

Required Certifications: 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 Required Testing:

About Us: Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust ISO 9001:2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation. SPECTRAFORCE is built on a concept of “human connection,” defined by our branding attitude of NEWJOBPHORIA®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential. Learn more at: http://www.spectraforce.com

Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at LOA@spectraforce.com if you require reasonable accommodation.