Spectraforce Technologies
Clinical Review Nurse - Prior Authorization
Spectraforce Technologies, Phoenix, Arizona, United States, 85003
Position Title:
Clinical Review Nurse - Prior Authorization
Work Location:
Arizona (must be independently licensed and living in AZ)
Assignment Duration:
5 Months
Work Schedule:
Standard hours (8-5), M-F, no OT required
Work Arrangement:
Remote to specific state, nationally sourced, or specific time zone? Arizona (must be independently licensed and living in AZ) 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.
Background & Context: This a backfill for UM specifically for med record review and to ensure compliance of CMS final rule of 7 day TAT starting 1/1/26.
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: 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: LPN - Licensed Practical Nurse - State Licensure required
For Health Net of California: RN license required
For Superior Health Plan: RN license required
Candidate Requirements: Education/Certification Required:
graduate of an accredited school of nursing or a BA degree and 2-4 years of related experience
Licensure Required:
LCSW, LMHC, LPC, LMFT, LMHP, or RN (state OR compact state licensure)
Years of experience required:
they should have at least 2 years in the behavioral health field; it would be a bonus if they also had some experience in utilization review
Disqualifiers / Additional qualities: Disqualifiers: not independently licensed in AZ, not living in AZ
Additional qualities to look for: expertise reviewing BH medical charts, treatment plans, any experience in BH utilization review
Top 3 must-have hard skills stack-ranked by importance: Behavioral health clinical review skills
Computer proficiency
Ability to multi-task and remain organized
? Education/Certification Required: graduate of an accredited school of nursing or a BA degree and 2-4 years of related experience Preferred:
Licensure Required: LCSW, LMHC, LPC, LMFT, LMHP, or RN (state OR compact state licensure) Preferred:
Years of experience required: they should have at least 2 years in the behavioral health field; it would be a bonus if they also had some experience in utilization review
Disqualifiers: not independently licensed in AZ, not living in AZ
Additional qualities to look for: expertise reviewing BH medical charts, treatment plans, any experience in BH utilization review
Top 3 must-have hard skills stack-ranked by importance
1 Behavioral health clinical review skills
2 Computer proficiency
3 Ability to multi-task and remain organized
Clinical Review Nurse - Prior Authorization
Work Location:
Arizona (must be independently licensed and living in AZ)
Assignment Duration:
5 Months
Work Schedule:
Standard hours (8-5), M-F, no OT required
Work Arrangement:
Remote to specific state, nationally sourced, or specific time zone? Arizona (must be independently licensed and living in AZ) 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.
Background & Context: This a backfill for UM specifically for med record review and to ensure compliance of CMS final rule of 7 day TAT starting 1/1/26.
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: 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: LPN - Licensed Practical Nurse - State Licensure required
For Health Net of California: RN license required
For Superior Health Plan: RN license required
Candidate Requirements: Education/Certification Required:
graduate of an accredited school of nursing or a BA degree and 2-4 years of related experience
Licensure Required:
LCSW, LMHC, LPC, LMFT, LMHP, or RN (state OR compact state licensure)
Years of experience required:
they should have at least 2 years in the behavioral health field; it would be a bonus if they also had some experience in utilization review
Disqualifiers / Additional qualities: Disqualifiers: not independently licensed in AZ, not living in AZ
Additional qualities to look for: expertise reviewing BH medical charts, treatment plans, any experience in BH utilization review
Top 3 must-have hard skills stack-ranked by importance: Behavioral health clinical review skills
Computer proficiency
Ability to multi-task and remain organized
? Education/Certification Required: graduate of an accredited school of nursing or a BA degree and 2-4 years of related experience Preferred:
Licensure Required: LCSW, LMHC, LPC, LMFT, LMHP, or RN (state OR compact state licensure) Preferred:
Years of experience required: they should have at least 2 years in the behavioral health field; it would be a bonus if they also had some experience in utilization review
Disqualifiers: not independently licensed in AZ, not living in AZ
Additional qualities to look for: expertise reviewing BH medical charts, treatment plans, any experience in BH utilization review
Top 3 must-have hard skills stack-ranked by importance
1 Behavioral health clinical review skills
2 Computer proficiency
3 Ability to multi-task and remain organized