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?

• Centene's commitment to diversity and inclusion is a part of who we are, and we support diversity of ideas and people by fostering open communication, encouraging inclusive decision-making, and actively promoting a team composition that values diverse backgrounds and perspectives.
• 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. This approach not only enhances job satisfaction but also drives high productivity making it an ideal setting for professionals eager to contribute meaningfully while growing their skills in a positive and inclusive workplace.

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. 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?

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. 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 criteri 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. 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 - video Required Testing or Assessment (by Vendor): Next Steps

• Do you have any upcoming PTO?

• Colleagues to cc/delegate

Lauren Jimenez