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 Sunday - Thursday 7am - 4pm 8am - 5pm 9am - 6pm 10pm - 7pm Shifts depend on what the team needs. Possible shifts in both PST and CST 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 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: 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

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.

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