Position Title: Clinical Review Nurse - Prior Authorization
Work Location: Remote: National (PST Time Zone).
Assignment Duration: 3 months
Work Schedule:

• 8am-5pm PST

• Work Mon-Fri 8a-8p PST with occasional weekend / holiday work with team rotating schedule.

Work Arrangement: Remote
Position Summary:

• Analyzes 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. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

?Background & Context:

• OR Medicaid Plans

• Friendly welcoming teams, work well together but process work independently.

• Increase need for staff as workload has increased.

• Needs to have willingness to learn, positive attitude, prior auth experience preferred but not exclusionary

?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.

• Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.

• Knowledge of Medicare and Medicaid regulations preferred.

• Knowledge of utilization management processes preferred.

?License/Certification: LPN - Licensed Practical Nurse - State Licensure required

• For certain plans: RN license required

• 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

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

Nice to haves: Willingness to learn, Positive attitude

Performance indicators: Up to 20 auth reviews per day

Top candidate review points (as ranked): 1) Previous experience with prior auth 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

 

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: 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	Previous experience with prior auth
		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: $ 37.00/hr.