Clinical Review Nurse - Prior Authorization
Clinical Review Nurse - Prior Authorization
Pacer Staffing LLC
United States
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Job Description
Job Title: Clinical Review Nurse - Prior Authorization
Location: Remote
Duration: 12 months (Possible Extension)
Shift Timing: Monday – Friday 8:00AM – 5:00PM
Job Summary
Position Purpose:
Job Title: Clinical Review Nurse - Prior Authorization
Location: Remote
Duration: 12 months (Possible Extension)
Shift Timing: Monday – Friday 8:00AM – 5:00PM
Job 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.
- Behavioral Health and Psychiatric Exp required!
- Reading treatment plans and making determinations
- Must have experience with all ages (pediatrics to geriatrics)
- Coordinate with providers via email and phone
- Experience as a Review Nurse (remotely)
- Experience with Prior auth
- Would accept an RN with Behavioral/Mental and Psychiatric health experience or would accept a Licensed Social Worker/Licensed Professional Counselor
- Navigating multiple systems
- Reviewing Medical Records
- 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.
- Registered Nuse or Social Worker/ Counselor Requires a master’s degree and AZ license
- 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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