Clinical Review Nurse - Prior Authorization

Title: Clinical Review Nurse - Prior Authorization
Duration: 06 Months (Possible extension or conversion FTE)
Location: Remote (AZ)
Shift is Monday - Friday 8-5:00 or 8:30-5

Day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD):

• Review for medical necessity-based on the criteria available
• Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
• Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.
• Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member.
• Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care.
• Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines.
• Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members.
• Provides feedback on opportunities to improve the authorization review process for members.
• Reviewing clinicals for procedures against the medical policies to determine medical necessity.

Required Skills/Experience:				Preferred Skills/ Experience:
1.	Previous PA experience and  experience in MM or UM.			1.	Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
2.	Strong computer skills-ability to navigate multiple systems			2.	Knowledge of Medicare and Medicaid regulations preferred.
3.				3.	Knowledge of utilization management processes preferred.
Education Requirement:		Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience.		Education Preferred:
Software Skills Required:
Required Certifications:		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		Required Testing:

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 39.44/hr.