Clinical Review Nurse - Prior Authorization
Clinical Review Nurse - Prior Authorization
Pacer Staffing LLC
United States
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Job Title: Clinical Review Nurse - Prior Authorization
Location: Remote
Duration: 3 months
Shift Timing: 8AM-5PM Mon-Fri (CST)
Summary
Responsibilities:
Location: Remote
Duration: 3 months
Shift Timing: 8AM-5PM Mon-Fri (CST)
Summary
Responsibilities:
- Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
- 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.
- Reviewing clinical procedures against the medical policies to determine medical necessity.
- LPN, RN, or BSN Licensed Nurse and able to legally practice in MO.
- 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.
- 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.
- 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.
- 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.
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Seniority level
Entry level -
Employment type
Contract -
Job function
Health Care Provider -
Industries
Staffing and Recruiting
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