Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Remote - PST and CST (No CA and NY candidates please)

Assignment Duration: 12 Months

Work Schedule: Shifts depend on what the team needs. Possible shifts in both PST and CST: 7am - 4pm, 8am - 5pm, 9am - 6pm, 10pm - 7pm. Schedules include Mon-Fri (rotational weekends and holidays), Sun-Thur, or Tues-Sat.

Work Arrangement: Remote - PST and CST

Position Summary:

Routinely reviews 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. Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Background & Context:

UM is highly focused on how we can be better partners to our external stakeholders, answering the question of "how can make it easy to work with us?" Specifically, this role will impact the member and provider experience, and this nurse will be responsible for ensuring communication excellence and unbiased application of policy and state regulations to ensure best possible member health outcomes. Candidates will be particularly interested in the collaborative and supportive team environment, enhanced by a democratic leadership style that values each team member's input and fosters a culture of creativity and continuous improvement.

Key Responsibilities:

• Routinely reviews 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.
• Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.

Qualification & Experience:

Candidate Requirements

Education/Certification
Required: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience

Preferred:

Licensure
Required: Required: RN- Registered Nurse/LPN - Licensed Practical Nurse - State Licensure required Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
Preferred: NV or Compact RN license

Years of experience required: Nice to haves: 2-4 years of related experience. Prior PA experience required, experience in InterQual/ Milliman, One Note, knowledge of Utilization Management (policies/regulations), at least 1 candidate must have NV license.

Disqualifiers: California and NY candidates

Additional qualities to look for: Team player, flexible

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

1
Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills experience.

2
Experience in InterQual or Milliman

3
Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded.