Job Description
Position Title: Clinical Review Nurse - Prior Authorization
Work Location: Remote (Oregon)
Assignment Duration: 3 months
Work Schedule: Mon-Fri 8am-5pm PST (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.
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. Mobile-Optimized JD Summary
• Remote Clinical Review Nurse role in OR: Analyze prior auth requests for medical necessity. Req: LPN/RN license in OR, 2+ yrs prior auth exp. Mon-Fri 8-5 PST w/ occasional weekends. Join a welcoming team handling increased workload!
| Education/Certification | Required: LPN/AS RN | Preferred: RN | ||
| Licensure | Required: RN, LPN, license needs to be in state of OR | Preferred: | ||
| 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 | |||
| 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 | |||
- 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: $ 37.00/hr.