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Mindlance

Clinical - Clinical Review Nurse - Prior Authorization

Mindlance, Texas City, Texas, us, 77592

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Job Profile 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.

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: LPN - Licensed Practical Nurse - State Licensure required For Health Net of California: RN license required For Superior Health Plan: RN license required

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

EEO:

"Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of - Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans."

What is the purpose of this team? Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative? Purpose: to perform prior authorization clinical reviews for Texas Marketplace members, additionally, will need to assist with non-par (out of network) redirections Team currently consists of 21 prior authorization nurses performing this work, it is a team effort, collaboration with team members is available to answer any questions and training will be handled at the team level total of 10 temps will be hired

(5 under Natalie 154880-1 10 AM-7PM CST, 5 under Molly 154878-1 8AM-5PM CST

),

no additional temps anticipated at this time) Typical Day in the Role

Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique? Day to day will include performing clinical reviews for prior authorization requests utilizing policies, Interqual, sending to the MD if needed. Additionally, will assist with out of network requests and redirecting to in network providers as needed. Performance expectations will include completing at least 20 clinical reviews per day and if assisting with out of network requests will perform 2 redirections per hour This role is unique as it supports Marketplace expansion for Texas Candidate Requirements

Education/Certification

Required: ADN, BSN - Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience Preferred:

Licensure

Required: RN Preferred: Years of experience required: 2-4 years

Disqualifiers: LVN

dditional qualities to look for: True care experience

Top 3 must-have hard skills stack-ranked by importance 1 daptable to change 2 quick processing, critical thinking 3 well organized

Candidate Review & Selection

Shortlisting process Candidate review & selection Interview information Onboard process and expectations Projected Manager Candidate Review Date: 1-2 days post shortlisting Type of Interviews: Teams CAMERA ON Required Testing or Assessment (by Vendor):

Next Steps

dditional background check requirements (List DFPS or other specialty checks here) Do you have any upcoming PTO? Colleagues to cc/delegate re there any training requirements (time off, alternate schedule, etc.)? Training will be handled at the team level, Alternate schedule 10am - 7pm