Job Description

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:

• 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.

Walk me through the day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD):

• 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

Education/Experience:

• 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.

License/Certification:

• 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

Responsibilities:

• 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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