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."

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?

Medicaid and Marketplace prior authorization reviews.


This position is needed to support key strategic initiatives and process improvement projects. Dedicated resources are required to ensure project deliverables are met while maintaining day-to-day operational responsibilities.
Fast-paced and collaborative, focused on regulatory compliance, operational excellence, and delivering timely, accurate authorization decisions.


Not at this time 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 prior authorization requests within turnaround times while maintaining quality standard.


14 to 16 reviews per day. Quality score of 95% or higher


Multi states with Medicaid and marketplace plans Candidate Requirements Education/Certification Required: graduated from accredited nursing program or Bachelor's degree in Nursing Preferred: Licensure Required: LPN or LVN Preferred: RN Years of experience required: 2-4 years of related experience


Disqualifiers: No Illinois or Compact license


dditional qualities to look for: compact license or multistate licensure

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

1 Prior experience with prior auth reviews 2 organized 3 Comfortable on the computer - especially MS Office Suite 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:
Teams - camera on Required Testing or Assessment (by Vendor): Next Steps

• Do you have any upcoming PTO?

Oct 30

• Colleagues to cc/delegate

Felicia Cox