Clinical Prior Authorization Reviwer

Appeals: Acceptable, but Prior Authorization is strongly preferred because Appeals are handled by Medical Directors. Work hours: Remote okay, but must work Arizona/Phoenix hours .

Job Title- Clinical Prior Authorization Reviwer
Location-phoenix, AZ OR Remote as well
Duration- 03 Month+ Contarct
Work hours: Remote okay, but must work Arizona/Phoenix hours. Reliability is important.

Pay Rate:$45/Hour On w2

What they really need:

• RN/Clinical background
• Strong Prior Authorization (PA) / Utilization Management (UM) experience
• Health Plan/Payer or Managed Care experience
• Medicaid Managed Care is highly preferred
• NCQA experience, especially UM domain, is a major plus
• CMS/AHCCCS experience helpful 
• Prior clinical audit/review experience preferred

Main job:

• Act as a second-level reviewer for Prior Authorization decisions.
• Review cases before information/letters are sent to providers.
• Verify the decision, clinical criteria, documentation, and accuracy.
• Ensure letters include who made the decision, criteria used, decision, and required information.
• Identify cases needing correction/replacement.

Important:
This is NOT primarily a training role. They want someone who already understands PA/UM processes. Training on their systems/processes will be provided.
 
Experience priority:

1. Prior Authorization / Pre-Service Review
2. Payer / Health Plan
3. Managed Care / Medicaid
4. NCQA UM
5. Clinical Audit
6. CMS / AHCCCS

 
Appeals: Acceptable, but Prior Authorization is strongly preferred because Appeals are handled by Medical Directors.
 
Systems: Care management system + CareRadius. Prior experience is helpful but not required.