Clinical Review Nurse - Prior Authorization
Clinical Review Nurse - Prior Authorization
Pacer Staffing LLC
Arizona, United States
See who Pacer Staffing LLC has hired for this role
Position Title: Clinical Review Nurse - Prior Authorization
Location: Remote | Candidate must live in Arizona
Duration: 6 Months
Schedule: Monday Friday 8-5 AZ time
License
Location: Remote | Candidate must live in Arizona
Duration: 6 Months
Schedule: Monday Friday 8-5 AZ time
License
- 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
- Review for medical necessity-based on the criteria available
- 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 clinicals for procedures against the medical policies to determine medical necessity.
- Previous PA experience and experience in MM or UM.
- Strong computer skills-ability to navigate multiple systems
- Requires Graduate from an Accredited School of Nursing or bachelor's degree in nursing and 2 4 years of related experience.
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Seniority level
Entry level -
Employment type
Full-time -
Job function
Health Care Provider -
Industries
Staffing and Recruiting
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