Clinical Review Nurse - Prior Authorization

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.