Spectraforce Technologies
Clinical Review Nurse - Prior Authorization
Spectraforce Technologies, Seattle, Washington, us, 98127
Position Title:
Clinical Review Nurse - Prior Authorization
Work Location:
Remote: WA / OR (PST Time Zone). WA can have a compact state license. OR is not a compact state, so they will have to have an OR license or be willing to get one.
Assignment Duration:
3 months
Work Schedule:
Shift: Tues- Saturday 8 am- 5 pm EST; no OT expectations Position Summary:
Performs medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteria Key Responsibilities: Works with healthcare providers and the 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 the 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
Qualification & Experience: Candidate Requirements- LPN/RN in Nursing; Must have at least 2 years prior experience in Prior Authorization with an Insurance company
Education/Certification Required: LPN/AS RN Preferred: RN
Licensure Required: i.e. RN, LPN Preferred:
Years of experience required
Disqualifiers
Best vs. average
Performance indicators
Must haves: 2 years experience with PA or IP auth reviews
Nice to haves: Previous experience with prior auth
Willingness to learn
Positive attitude
Performance indicators: Up to 20 auth reviews per day
Top 3 must-have hard skills
Level of experience with each
Stack-ranked by importance
Candidate Review & Selection Willingness to learn the WA / OR Medicaid Plan Prior Auth Review
Must be a team player that works well independently
Must be willing to work a flexible schedule of 1 weekend a month, a few holidays per year
Clinical Review Nurse - Prior Authorization
Work Location:
Remote: WA / OR (PST Time Zone). WA can have a compact state license. OR is not a compact state, so they will have to have an OR license or be willing to get one.
Assignment Duration:
3 months
Work Schedule:
Shift: Tues- Saturday 8 am- 5 pm EST; no OT expectations Position Summary:
Performs medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteria Key Responsibilities: Works with healthcare providers and the 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 the 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
Qualification & Experience: Candidate Requirements- LPN/RN in Nursing; Must have at least 2 years prior experience in Prior Authorization with an Insurance company
Education/Certification Required: LPN/AS RN Preferred: RN
Licensure Required: i.e. RN, LPN Preferred:
Years of experience required
Disqualifiers
Best vs. average
Performance indicators
Must haves: 2 years experience with PA or IP auth reviews
Nice to haves: Previous experience with prior auth
Willingness to learn
Positive attitude
Performance indicators: Up to 20 auth reviews per day
Top 3 must-have hard skills
Level of experience with each
Stack-ranked by importance
Candidate Review & Selection Willingness to learn the WA / OR Medicaid Plan Prior Auth Review
Must be a team player that works well independently
Must be willing to work a flexible schedule of 1 weekend a month, a few holidays per year