Clinical - Clinical Review Nurse - Prior Authorization

Job Title: Clinical Review Nurse -Prior Authorization


Location: Remote


Duration: 12 months


Schedule: Mon - Fri (rotational weekends and holidays)


XXXX: XXXXXXXXXXX/hr. on w2


Possible shifts in both PST and CST:

• 7am - 4pm
• 8am - 5pm
• 9am - 6pm
• 10am - 7pm

Typical Day in the Role :

• 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.

Education/Certification:


Required:

• Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience

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.


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

• Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills experience.
• Experience in InterQual or Milliman.
• Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded.

Disqualifiers: California and NY candidates


Additional qualities to look for: Team player, flexible