Position Title: Clinical Review Nurse - Prior Authorization
Work Location: Remote: WA / OR (PST Time Zone). WA can have a compact state license. OR is not a compact state, so they will have to have an OR license or be willing to get one.
Assignment Duration: 3 months
Work Schedule: Shift: Tues- Saturday 8 am- 5 pm EST; no OT expectations

Position Summary: Performs medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteria

Key Responsibilities:

• Works with healthcare providers and the 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 the 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

Qualification & Experience:

• Candidate Requirements- LPN/RN in Nursing; Must have at least 2 years prior experience in Prior Authorization with an Insurance company

• Education/Certification Required: LPN/AS RN Preferred: RN

• Licensure Required: i.e. RN, LPN Preferred:

• Years of experience required

• Disqualifiers

• Best vs. average

• Performance indicators

• Must haves: 2 years experience with PA or IP auth reviews

• Nice to haves:

  • Previous experience with prior auth

  • Willingness to learn

  • Positive attitude

• Performance indicators:

  • Up to 20 auth reviews per day

• Top 3 must-have hard skills

• Level of experience with each

• Stack-ranked by importance

• Candidate Review & Selection

  1. Willingness to learn the WA / OR Medicaid Plan Prior Auth Review

  2. Must be a team player that works well independently

  3. Must be willing to work a flexible schedule of 1 weekend a month, a few holidays per year

 
 
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: $ 39.00/hr.