Spectraforce Technologies
Clinical Review Nurse - Prior Authorization
Spectraforce Technologies, Las Vegas, Nevada, us, 89105
Position Title: Clinical Review Nurse - Prior Authorization
Work Location: Fully Remote
Assignment Duration: 3 months (Possibility to extend and/or convert to FTE)
Work Schedule: M-Fri 8AM-5PM PST time
Training Schedule: 3 weeks M-Fri 8AM-5PM PST time ON CAMERA - NO TIME OFF
Work Arrangement: Remote, Candidate can reside anywhere but MUST HAVE NV license (not a compact state) Position Summary:
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. May call a provider for more information but will not be in contact with members. Background & Context: Prior Authorization Clinical Review Nurse May call a provider for more information (RFI, call or fax) but will not be in contact with members. Trucare and Microsoft applications
Key Responsibilities: 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
Qualification & Experience: Required: Requires Graduate from an Accredited School of Nursing RN/LPN or Bachelor's degree in Nursing and 2 - 4 years of related experience. Required: LPN, RN, or BSN MUST HAVE NV license Years of experience required: 2-4 years experience in health authorizations, medical terminology/hipaa guidelines Disqualifiers: NA Additional qualities to look for: Top 3 must-have hard skills stack-ranked by importance 1 Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred/analytical and critical thinking skills/problem solving/attention to detail 2 Knowledge of Medicaid regulations preferred. 3 Knowledge of utilization management processes preferred.
Education/Certification Required: Requires Graduate from an Accredited School of Nursing RN/LPN or Bachelor's degree in Nursing and 2 - 4 years of related experience.
Preferred:
Licensure Required: LPN, RN, or BSN MUST HAVE NV license Preferred:
Years of experience required: 2-4 years experience in health authorizations, medical terminology/hipaa guidelines
Disqualifiers: NA
Additional qualities to look for:
Top 3 must-have hard skills stack-ranked by importance
1 Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred/analytical and critical thinking skills/problem solving/attention to detail
2 Knowledge of Medicaid regulations preferred.
3 Knowledge of utilization management processes preferred.
Work Location: Fully Remote
Assignment Duration: 3 months (Possibility to extend and/or convert to FTE)
Work Schedule: M-Fri 8AM-5PM PST time
Training Schedule: 3 weeks M-Fri 8AM-5PM PST time ON CAMERA - NO TIME OFF
Work Arrangement: Remote, Candidate can reside anywhere but MUST HAVE NV license (not a compact state) Position Summary:
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. May call a provider for more information but will not be in contact with members. Background & Context: Prior Authorization Clinical Review Nurse May call a provider for more information (RFI, call or fax) but will not be in contact with members. Trucare and Microsoft applications
Key Responsibilities: 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
Qualification & Experience: Required: Requires Graduate from an Accredited School of Nursing RN/LPN or Bachelor's degree in Nursing and 2 - 4 years of related experience. Required: LPN, RN, or BSN MUST HAVE NV license Years of experience required: 2-4 years experience in health authorizations, medical terminology/hipaa guidelines Disqualifiers: NA Additional qualities to look for: Top 3 must-have hard skills stack-ranked by importance 1 Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred/analytical and critical thinking skills/problem solving/attention to detail 2 Knowledge of Medicaid regulations preferred. 3 Knowledge of utilization management processes preferred.
Education/Certification Required: Requires Graduate from an Accredited School of Nursing RN/LPN or Bachelor's degree in Nursing and 2 - 4 years of related experience.
Preferred:
Licensure Required: LPN, RN, or BSN MUST HAVE NV license Preferred:
Years of experience required: 2-4 years experience in health authorizations, medical terminology/hipaa guidelines
Disqualifiers: NA
Additional qualities to look for:
Top 3 must-have hard skills stack-ranked by importance
1 Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred/analytical and critical thinking skills/problem solving/attention to detail
2 Knowledge of Medicaid regulations preferred.
3 Knowledge of utilization management processes preferred.