Position Title: Clinical Review Nurse – Prior Authorization
Work Location: Fully Remote – Candidates must reside in NV
Assignment Duration: 3 months (Possibility to extend and/or convert to FTE)
Work Schedule: M-Fri 8AM-5PM PST time
Training Schedule: Training 3 weeks M-Fri 8AM-5PM PST time ON CAMERA - NO TIME OFF.
Work Arrangement: Remote (NV only)

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

Candidate Requirements  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.
Education/Certification	Required: Requires Graduate from an Accredited School of Nursing RN/LPN or Bachelor’s degree in Nursing and 2 – 4 years of related experience.			Preferred:
Licensure	Required: MUST BE RN or BSN MUST HAVE A NV LICENSE			Preferred:
Years of experience required: MUST HAVE 2-4 years experience in health prior authorizations, case management, medical terminology/hipaa guidelines,   Disqualifiers: job hopping (want someone that will eventually be permanent at Centene if the position comes available within department) PLEASE STATE IF CONTRACT ROLE.   Additional qualities to look for:
Top 3 must-have hard skills stack-ranked by importance		1	Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred/analytical and critical thinking skills/problem solving/attention to detail
		2	Knowledge of Medicaid regulations preferred.
		3	Knowledge of utilization management processes preferred.

 
 
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.