Mindlance
Clinical - Clinical Review Nurse - Prior Authorization - J00927
Mindlance, Brackettville, Texas, United States, 78832
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.
Story Behind the Need
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?
Prior Authorization team for pa requests from non-contracted providers. Team consists of 30-32 employees; this team consist of 3 smaller teams within it. Redirection team, clinical review team, and single case agreement team. All work closely together. This position is for the clinical review team. No Not 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?
Reviewing PA requests, opening your auths, reviewing for medical necessity and then determining them. Some team meetings may occur throughout the week CAMERA ON . Some phone time is required as the nurse may need to call for additional information to provider to support their review, or to inform the provider if the auth has been denied. 18-20 auths per day, that is averaged every month. Expectation is 95% productivity every month.
Candidate Requirements Education/Certification Required: LVN/RN Preferred: Licensure Required: LVN/RN license MUST BE COMPACT Preferred: 1+ year of authorization/prior auth nursing exp, navigating Microsoft Office with 3 screens utilizing different systems at the same time
Disqualifiers Job hopping (please state if contract role), most recent job must be in related field, illiteracy,
Additional Qualities to Look for
Top 3 must-have hard skills stack-ranked by importance
Knowledge of Insurance Prior Authorization Processes/abide by consistent policy changes
Ability to Perform in a Fast-Paced, High-Volume Environment
Organizational Skills/multitasking skills/computer literacy/independent work/
Candidate Review & Selection
Shortlisting process
Candidate review & selection
Interview information
Onboard process and expectations
Projected Manager Candidate Review Date 24 hours of being qualified over
Type of Interviews Teams CAMERA ON Required Testing or Assessment (by Vendor): AGENCIES - Computer literacy skills test prior to being submitted on Req
#J-18808-Ljbffr
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.
Story Behind the Need
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?
Prior Authorization team for pa requests from non-contracted providers. Team consists of 30-32 employees; this team consist of 3 smaller teams within it. Redirection team, clinical review team, and single case agreement team. All work closely together. This position is for the clinical review team. No Not 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?
Reviewing PA requests, opening your auths, reviewing for medical necessity and then determining them. Some team meetings may occur throughout the week CAMERA ON . Some phone time is required as the nurse may need to call for additional information to provider to support their review, or to inform the provider if the auth has been denied. 18-20 auths per day, that is averaged every month. Expectation is 95% productivity every month.
Candidate Requirements Education/Certification Required: LVN/RN Preferred: Licensure Required: LVN/RN license MUST BE COMPACT Preferred: 1+ year of authorization/prior auth nursing exp, navigating Microsoft Office with 3 screens utilizing different systems at the same time
Disqualifiers Job hopping (please state if contract role), most recent job must be in related field, illiteracy,
Additional Qualities to Look for
Top 3 must-have hard skills stack-ranked by importance
Knowledge of Insurance Prior Authorization Processes/abide by consistent policy changes
Ability to Perform in a Fast-Paced, High-Volume Environment
Organizational Skills/multitasking skills/computer literacy/independent work/
Candidate Review & Selection
Shortlisting process
Candidate review & selection
Interview information
Onboard process and expectations
Projected Manager Candidate Review Date 24 hours of being qualified over
Type of Interviews Teams CAMERA ON Required Testing or Assessment (by Vendor): AGENCIES - Computer literacy skills test prior to being submitted on Req
#J-18808-Ljbffr