A-Line Staffing Solutions
Clinical Review Nurse - Prior Authorization - J00927
A-Line Staffing Solutions, Raleigh, North Carolina, United States
Clinical Review Nurse - Prior Authorization - J00927
Job Title: Clinical Review Nurse - Prior Authorization - J00927
Location: Various, NC
Job Description
Analyzes prior authorization requests to determine medical necessity of services and appropriate level of care based on standards, contractual requirements, and benefit coverage.
Recommends appropriate care options to medical teams to enhance quality and cost efficiency.
Performs clinical reviews to assess the medical appropriateness of care in line with regulatory guidelines.
Coordinates with healthcare providers and authorization teams to ensure timely review and approval of services.
Escalates authorization requests to Medical Directors for review when necessary.
Assists with member transfer or discharge plans to facilitate timely transitions between care levels and facilities.
Critical Information
Remote work available.
Shift and hours to be determined; compliance and environment details as per company policy.
Education / Licenses Needed
Graduate from an accredited school of nursing or have a bachelor's degree in nursing.
License: LPN – Licensed Practical Nurse (state licensure required). For Health Net of California: RN license required. For Superior Health Plan: RN license required.
Benefits
Benefits available to full‑time employees after 90 days of employment.
401(k) with company match available after 1 year of service.
This is an AI‑formatted job description; recruiter confirmation required.
Seniority Level
Entry level
Employment Type
Full‑time
Job Function
Health Care Provider
Industries
Staffing and Recruiting
#J-18808-Ljbffr
Location: Various, NC
Job Description
Analyzes prior authorization requests to determine medical necessity of services and appropriate level of care based on standards, contractual requirements, and benefit coverage.
Recommends appropriate care options to medical teams to enhance quality and cost efficiency.
Performs clinical reviews to assess the medical appropriateness of care in line with regulatory guidelines.
Coordinates with healthcare providers and authorization teams to ensure timely review and approval of services.
Escalates authorization requests to Medical Directors for review when necessary.
Assists with member transfer or discharge plans to facilitate timely transitions between care levels and facilities.
Critical Information
Remote work available.
Shift and hours to be determined; compliance and environment details as per company policy.
Education / Licenses Needed
Graduate from an accredited school of nursing or have a bachelor's degree in nursing.
License: LPN – Licensed Practical Nurse (state licensure required). For Health Net of California: RN license required. For Superior Health Plan: RN license required.
Benefits
Benefits available to full‑time employees after 90 days of employment.
401(k) with company match available after 1 year of service.
This is an AI‑formatted job description; recruiter confirmation required.
Seniority Level
Entry level
Employment Type
Full‑time
Job Function
Health Care Provider
Industries
Staffing and Recruiting
#J-18808-Ljbffr