Clinical - Clinical Review Nurse - Prior Authorization

Job Profile Summary


Position Purpose:
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.


Education/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 Health Net of California: RN license required
For Superior Health Plan: RN license required


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


EEO:


"Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of - Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans."

Job Profile Summary


Position Purpose:
nalyzes 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.


Education/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:
RN license required-Compact Licensure


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


ssists 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


ssists 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

Story Behind the Need

• What is the purpose of this team?
• What is driving this need? (ex. Backfill for FTE or CW, new project, business growth)
• Describe the surrounding team (team culture, work environment, etc.) & key projects.
• Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?

• The Outpatient Prior Authorization team reviews authorization requests for Medicare, Medicaid, and Dual Eligible populations to ensure services meet medical necessity criteria and regulatory requirements while supporting timely access to care.
• The need is being driven by continued growth in the product line and increasing authorization volume. Additional temporary nursing support is needed to maintain turnaround times, workload balance, and operational performance.
• The team is a fully remote group of Prior Authorization nurses who work collaboratively in a supportive and highly engaged environment. Team members work closely together and have access to leadership and peer support as needed. The team is focused on quality, regulatory compliance, productivity, and timely member access to care.
• This request is part of a larger hiring initiative to support growth within the Outpatient Prior Authorization department. Nine (9) temporary RN positions are being requested.

Typical Day in the Role

• Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD).
• What are performance expectations/metrics?
• What makes this role unique?

• Review outpatient prior authorization requests for Dual Eligible populations (Medicare and Medicaid), Work assigned cases from designated work queues and daily assignments, Utilize TrueCare Classic and Cloud platforms to complete utilization management reviews, Apply clinical criteria and organizational guidelines to determine medical necessity and appropriateness of requested services, Document review findings and authorization decisions accurately and timely, Communicate with providers and internal departments as needed regarding authorization requests and clinical information.
• Productivity target of approximately 1.85 reviews per hour , Meet established turnaround time requirements, Maintain quality and documentation standards, Adhere to departmental workflows and regulatory requirements.
• Opportunity to work across Dual eligible populations, collaborative and supportive team environment, fully remote position with established workflows, resources and leadership support, direct impact on member access to care and authorization determination.

Candidate Requirements Education/Certification Required: Graduate of an accredited School of Nursing and Active Registered Nurse (RN) license Preferred: Bachelor's Degree in Nursing (BSN), Prior Utilization Management experience Licensure Required: Active Compact RN License Preferred: Years of experience required: Minimum 2 years of clinical nursing experience, 2-4 years of Utilization Management, Prior Authorization, Case Management, or related experience preferred


Disqualifiers: LPN/LVN license only, Inactive or restricted nursing license, Non-Compact RN licensure, Lack of relevant clinical experience


dditional qualities to look for: Strong critical thinking and clinical judgment, Ability to work independently in a remote environment, Strong organizational and time management skills, Effective written and verbal communication, Ability to adapt to changing priorities and workflows

• Top 3 must-have hard skills stack-ranked by importance

1 Utilization Management & Clinical Review

• bility to review outpatient prior authorization requests for medical necessity
• Experience applying InterQual, MCG, or similar clinical criteria
• Strong clinical documentation review skills

2 uthorization Workflow & Documentation

• Experience with prior authorization processes
• ccurate documentation and case management skills
• bility to manage multiple work items while meeting turnaround times

3 Regulatory & Compliance Knowledge

• Knowledge of Medicare and/or Medicaid programs
• Understanding of utilization management regulations and requirements
• bility to follow established policies, workflows, and compliance standards

Candidate Review & Selection

• Shortlisting process
• Candidate review & selection
• Interview information
• Onboard process and expectations

Projected Manager Candidate Review Date: 1-2 days post shortlisting
Type of Interviews:
Camera on video (Teams) Required Testing or Assessment (by Vendor): N/ Next Steps

• Do you have any upcoming PTO?

No

• Colleagues to cc/delegate

Kayley Tonna, Lyndsey Zuccarello, Kelli Polchowski, Steph Green