Clinical Review Nurse - Prior Authorization

Position Title : Clinical Review Nurse - Prior Authorization

Work Location : Remote

Assignment Duration : 12 months

Work Schedule : Mon - Fri (rotational weekends and holidays) - Shifts depend on what the team needs.

Possible shifts in both PST and CST

7am - 4pm

8am - 5pm

9am - 6pm

10pm - 7pm

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

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.

Candidate Requirements

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

Preferred:

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.