Position Title: Clinical Review Nurse - Prior Authorization
Work Location: Remote
Assignment Duration: 3 months (Possibility to convert)
Work Arrangement: Remote
Work Schedule: M-F 8:30-5pm EST
Position Summary:
Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
Background & Context:
This team will be responsible for redirecting Out of Network authorizations to In Network providers due to anticipated large volume from a potential non-renewal.
Key Responsibilities:
• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
• 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
• Performs other duties as assigned
• Complies with all policies and standards
Qualification & Experience:
• Requires Graduate from an Accredited School of Nursing OR Bachelor’s degree in Nursing AND 2 – 4 years of related experience. • Required: LPN or RN
• 2-4 years of Prior Facets experience, knowledge of clinical terminology, prior office or insurance experience, familiar with MCG or Interqual, phone etiquette
| Education/Certification | Required: Requires Graduate from an Accredited School of Nursing OR Bachelor’s degree in Nursing AND 2 – 4 years of related experience. | Preferred: | ||
| Licensure | Required: LPN or RN | Preferred: RN | ||
| Years of experience required: 2-4 years of Prior Facets experience, knowledge of clinical terminology, prior office or insurance experience, familiar with MCG or Interqual, phone etiquette Disqualifiers: Not having a professional environment to work remotely, not having reliable internet (please use hotspot or get to a secure place with wifi to continue working) Additional qualities to look for: Prior Facets experience, knowledge of clinical terminology, prior office or insurance experience, familiar with MCG or Interqual | ||||
| 1 | Tech savvy, ability to work in multitask in multiple systems at once while speaking | ||
| 2 | Strong communication skills, written and verbal, phone etiquette | |||
| 3 | Clinical documentation A MUST | |||