Job Description
Position Title: Clinical Review Nurse – Prior Authorization
Work Location: Remote - California, Must either reside in CA or hold a CA license, and work hours listed
Assignment Duration: 12 months (Extension & Contract-to-hire)
Work Schedule: Training 8 am-5 pm PST – about a month-long learning journey /Work schedule 8 am-5 pm PST
Work Arrangement: Remote
Responsibilities:
o Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
o Productivity 17-20 reviews a day and quality expectations must be met
o Partners with interdepartmental teams on projects within utilization management as part of the clinical review team
o Partners and works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
o Assesses members and/or families for post discharge needs and provide education on discharge planning options based on diagnoses, prognoses, resources, and/or preferences
o Manages and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
o Manages and collaborates with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
o Provides education to providers on utilization processes to ensure high quality appropriate care to members
o Partners with leadership to identify opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
o Oversees concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
o Provides insight and guidance on concurrent reviews to determine overall health of member, review the type of care being delivered to member, and approving treatment needs including discharge planning
o Provides guidance and expert knowledge, as appropriate, to utilization management team to address issues and validate the necessity and setting of care being delivered to the member
o Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
o Oversees member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
o Collaborates with care management on referral of members as appropriate
o Provides subject matter expertise based on prior experience as well as training to other team members
o Manages reporting to identify trends and provides recommendations to various teams
o Performs other duties as assigned
o Complies with all policies and standards
| Candidate Requirements | ||||
| Education/Certification | ADN or above Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience | Preferred: | ||
| Licensure | Required: California RN license ONLY | Preferred: | ||
| Years of experience required: 2 – 4 years of related experience - concurrent review / interqual experience Preferred: Background with Centene highly preferred ; Trucare experience Disqualifiers: unmotivated, inability to work autonomously, no time off for first 90 days, Additional qualities to look for: | ||||
| 1 | Communication skills a must | ||
| 2 | FAST PACED, attention to detail, tech savvy | |||
| 3 | Interqual, one note, word, excel, teams, | |||
- For information on benefits, equal opportunity employment, and location-specific applicant notices, click here
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: $ 38.00/hr.