Position Title: Clinical Review Nurse - Prior Authorization
Work Location: Remote-NC
Assignment Duration: 3 months
Work Schedule: Monday- Friday 8am-5pm EST
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.

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.
• LPN - Licensed Practical Nurse - State Licensure required

Education/Certification	Required: Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.			Preferred:
Licensure	Required:  LPN  - Licensed Practical Nurse - State Licensure   required			Preferred: RN
Years of experience required Disqualifiers Best vs. average Performance indicators		Must haves: 2 years experience with PA auth reviews Nice to haves: Previous experience with NC State Criteria/ InterQual Criteria Disqualifiers:   Performance indicators: 15 Auths reviews per day
Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection		1	Must have 2 years prior exp in PA or IP with an insurance company
		2	Must be a team player
		3	Must be willing to work an alt schedule of Monday - Friday

 
 
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.