IMCS Ltd
Job Title
Clinical Review Nurse - Prior Authorization Duration
3 months Contract Shift Type
Monday-Friday 8 am-5pm EST Job Duties
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. 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. Work Mon-Fri 8a-8p PST with occasional weekend / holiday work with team rotating schedule. Years of Experience Required
2 years’ experience with PA or IP auth reviews Previous experience with prior auth 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 Education / Certification Required
Associates Licensure Required
RN, LPN, license needs to be in state of OR Seniority Level
Entry level Employment Type
Contract Job Function
Health Care Provider Industries
Facilities Services
#J-18808-Ljbffr
Clinical Review Nurse - Prior Authorization Duration
3 months Contract Shift Type
Monday-Friday 8 am-5pm EST Job Duties
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. 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. Work Mon-Fri 8a-8p PST with occasional weekend / holiday work with team rotating schedule. Years of Experience Required
2 years’ experience with PA or IP auth reviews Previous experience with prior auth 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 Education / Certification Required
Associates Licensure Required
RN, LPN, license needs to be in state of OR Seniority Level
Entry level Employment Type
Contract Job Function
Health Care Provider Industries
Facilities Services
#J-18808-Ljbffr