Clinical Review Nurse

Summary:

• Work Mode: Remote
• Duration: 3 months, with potential to convert to full-time employment
• Work Hours: Monday to Friday, 8:30 AM - 5:00 PM EST

Responsibilities:

• Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
• Work with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.
• Coordinate as appropriate with healthcare providers and interdepartmental teams to assess medical necessity of care of member.
• Escalate prior authorization requests to Medical Directors as appropriate to determine appropriateness of care.
• Assist with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collect, document, and maintain all member’s clinical information in health management systems to ensure compliance with regulatory guidelines.
• Provide education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members.
• Provide feedback on opportunities to improve the authorization review process for members.
• Perform other duties as assigned.
• Comply with all policies and standards.

Requirements:

• Graduate from an Accredited School of Nursing OR Bachelor’s degree in Nursing.
• Minimum 2 years of related experience.
• Licensure: LPN or RN.
• Prior Facets experience, knowledge of clinical terminology, prior office or insurance experience.
• Familiarity with MCG or Interqual.
• Strong communication skills, written and verbal, with phone etiquette.
• Tech savvy, ability to multitask in multiple systems at once while speaking.
• Clinical documentation skills are essential.

Preferred Skills:

• RN licensure preferred.