Spectraforce Technologies
Clinical Review Nurse - Prior Authorization
Spectraforce Technologies, Raleigh, North Carolina, United States, 27601
Position Title:
Clinical Review Nurse - Prior Authorization Work Location:
Remote: National (PST Time Zone). Assignment Duration:
3 months Work Schedule: 8am-5pm PST Work Mon-Fri 8a-8p PST with occasional weekend / holiday work with team rotating schedule. Work Arrangement:
Remote 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: OR Medicaid Plans Friendly welcoming teams, work well together but process work independently. Increase need for staff as workload has increased. Needs to have willingness to learn, positive attitude, prior auth experience preferred but not exclusionary 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 certain plans: RN license required 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 Must haves:
2 years of experience with PA or IP auth reviews Nice to haves:
Willingness to learn, Positive attitude Performance indicators:
Up to 20 auth reviews per day Top candidate review points (as ranked):
1) Previous experience with prior auth 2) Must be a team player that works well independently 3) Must be willing to work a flexible schedule of 1 weekend a month, a few holidays per year
#J-18808-Ljbffr
Clinical Review Nurse - Prior Authorization Work Location:
Remote: National (PST Time Zone). Assignment Duration:
3 months Work Schedule: 8am-5pm PST Work Mon-Fri 8a-8p PST with occasional weekend / holiday work with team rotating schedule. Work Arrangement:
Remote 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: OR Medicaid Plans Friendly welcoming teams, work well together but process work independently. Increase need for staff as workload has increased. Needs to have willingness to learn, positive attitude, prior auth experience preferred but not exclusionary 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 certain plans: RN license required 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 Must haves:
2 years of experience with PA or IP auth reviews Nice to haves:
Willingness to learn, Positive attitude Performance indicators:
Up to 20 auth reviews per day Top candidate review points (as ranked):
1) Previous experience with prior auth 2) Must be a team player that works well independently 3) Must be willing to work a flexible schedule of 1 weekend a month, a few holidays per year
#J-18808-Ljbffr