Mindlance
Clinical - Clinical Review Nurse - Prior Authorization
Mindlance, Philadelphia, Pennsylvania, United States, 19700
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."
Job Profile Summary
Position Purpose: nalyzes 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 criteri
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
ssists 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
ssists 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 Story Behind the Need - Business Group & Key Projects Health plan or business unit Team culture Surrounding team & key projects Purpose of this team Reason for the request Motivators for this need ny additional upcoming hiring needs? Small knit team Bi-weekly meeting, works closely together ssist other teams with work Backfilling permanent position
Typical Day in the Role
Daily schedule & OT expectations Typical task breakdown and rhythm Interaction level with team Work environment description Review authorization request that come in for pre service Reach out to providers for information and follow up pproval letters to providers Consider prior authorization for S&P Fast pace independent environment Compelling Story & Candidate Value Proposition
What makes this role interesting? Points about team culture Competitive market comparison Unique selling points Value added or experience gained Candidate Requirements
Education/Certification
Required: Bachelor's degree in Nursing and 2 - 4 years of related experience. Preferred:
Licensure
Required: .RN, BSN, LPN, compact license Preferred:
Years of experience required Disqualifiers Best vs. average Performance indicators Must haves: Microsoft Office, Data Entry Sense of urgency ccountable
Nice to haves: More than 50 WPM Disqualifiers: No job hopping unless contract work
Performance indicators
: 95% or more of accuracy /2-2.5 authorizations per hour
Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection 1 Utilization Management experience 2 cute care experience 3
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."
Job Profile Summary
Position Purpose: nalyzes 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 criteri
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
ssists 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
ssists 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 Story Behind the Need - Business Group & Key Projects Health plan or business unit Team culture Surrounding team & key projects Purpose of this team Reason for the request Motivators for this need ny additional upcoming hiring needs? Small knit team Bi-weekly meeting, works closely together ssist other teams with work Backfilling permanent position
Typical Day in the Role
Daily schedule & OT expectations Typical task breakdown and rhythm Interaction level with team Work environment description Review authorization request that come in for pre service Reach out to providers for information and follow up pproval letters to providers Consider prior authorization for S&P Fast pace independent environment Compelling Story & Candidate Value Proposition
What makes this role interesting? Points about team culture Competitive market comparison Unique selling points Value added or experience gained Candidate Requirements
Education/Certification
Required: Bachelor's degree in Nursing and 2 - 4 years of related experience. Preferred:
Licensure
Required: .RN, BSN, LPN, compact license Preferred:
Years of experience required Disqualifiers Best vs. average Performance indicators Must haves: Microsoft Office, Data Entry Sense of urgency ccountable
Nice to haves: More than 50 WPM Disqualifiers: No job hopping unless contract work
Performance indicators
: 95% or more of accuracy /2-2.5 authorizations per hour
Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection 1 Utilization Management experience 2 cute care experience 3