Summary:
Duration: 1 year
Work Mode: Remote – US- MST, CST, EST time zone candidates only
Schedule: 8 to 5 CST (1 hour lunch)
- Sunday through Thursday
- Tuesday through Saturday
- Wednesday through Sunday
Responsibilities:
- Analyze all 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.
- 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:
- Graduated from accredited nursing program or Bachelor’s degree in Nursing.
- Required Licensure: LPN or LVN.
- Minimum 2 years of related experience.
- Disqualifiers: No Illinois or Compact license.
Preferred Skills:
- Prior experience with prior authorization reviews.
- Organized.
- Comfortable on the computer – especially MS Office Suite.
- Additional qualities: Compact license or multistate licensure.