Title: Clinical Review Nurse - Prior Authorization
Location: Remote
Duration: 12 Months
Schedule: Sun - Thur | Possible shifts in both PST and CST
7am 4pm/8am 5pm/9am 6pm/10Am 7pm
PR: $38-43.00/HR
Responsibilities
Routinely reviews 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.
Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
Education And License Required
Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience
RN- Registered Nurse/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
Years of experience required
Nice to haves: 2-4 years of related experience. Prior PA experience required, experience in InterQual/ Milliman, One Note, knowledge of Utilization Management (policies/regulations), at least 1 candidate must have NV license.
Additional qualities to look for
Skills
Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills experience.
Experience in InterQual or Milliman
Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded.