Clinical Review Nurse - Prior Authorization

About the position

The position involves analyzing prior authorization requests to determine the medical necessity of services and the appropriate level of care in accordance with national standards and member benefit coverage. The role is crucial in promoting quality and cost-effectiveness in medical care, requiring collaboration with healthcare providers and internal teams to ensure timely reviews and compliance with regulatory guidelines.

Responsibilities
? Analyze prior authorization requests to determine medical necessity of service and appropriate level of care.
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? Perform medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines.
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? Work with healthcare providers and authorization team to ensure timely review of services and requests.
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? Coordinate with healthcare providers and interdepartmental teams to assess medical necessity of care.
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? Escalate prior authorization requests to Medical Directors as appropriate.
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? Assist with service authorization requests for member transfer or discharge plans.
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? Collect, document, and maintain all member's clinical information in health management systems.
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? Provide education to providers and interdepartmental teams on utilization processes.
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? Provide feedback on opportunities to improve the authorization review process.
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? Perform other duties as assigned.

Requirements
? Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing.
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? 2 - 4 years of related experience.
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? Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
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? Knowledge of Medicare and Medicaid regulations preferred.
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? Knowledge of utilization management processes preferred.
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? LPN - Licensed Practical Nurse - State Licensure required.

Nice-to-haves

Benefits
? Competitive pay
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? Health insurance
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? 401K and stock purchase plans
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? Tuition reimbursement
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? Paid time off plus holidays
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? Flexible work schedules (remote, hybrid, field, or office)

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