Job Title: Clinical Review Nurse -Prior Authorization
Location: Remote
Duration: 12 months
Schedule: Mon - Fri (rotational weekends and holidays)
XXXX: XXXXXXXXXXX/hr. on w2
Possible shifts in both PST and CST:
- 7am 4pm
- 8am 5pm
- 9am 6pm
- 10am 7pm
Typical Day in the Role:
- 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/Certification:
Required:
- Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience
Licensure
Required:
- Required: 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
Preferred: NV or Compact RN license
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.
Top 3 must-have hard skills stack-ranked by importance:
- 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.
Disqualifiers: California and NY candidates
Additional qualities to look for: Team player, flexible