Spectraforce Technologies
Clinical Review Nurse - Prior Authorization
Spectraforce Technologies, Raleigh, North Carolina, United States, 27603
Position Title : Clinical Review Nurse - Prior Authorization
Work Location : Remote (Oregon)
Assignment Duration : 3 months
Work Schedule : Mon-Fri 8am-5pm PST (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.
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. Mobile-Optimized JD Summary
* Remote Clinical Review Nurse role in OR: Analyze prior auth requests for medical necessity. Req: LPN/RN license in OR, 2+ yrs prior auth exp. Mon-Fri 8-5 PST w/ occasional weekends. Join a welcoming team handling increased workload!
Education/Certification Required: LPN/AS RN Preferred: RN
Licensure Required:
RN, LPN, license needs to be in state of OR Preferred:
Years of experience required
Disqualifiers
Best vs. average
Performance indicators
Must haves: 2 years 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 3 must-have hard skills
Level of experience with each
Stack-ranked by importance
Candidate Review & Selection
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
Work Location : Remote (Oregon)
Assignment Duration : 3 months
Work Schedule : Mon-Fri 8am-5pm PST (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.
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. Mobile-Optimized JD Summary
* Remote Clinical Review Nurse role in OR: Analyze prior auth requests for medical necessity. Req: LPN/RN license in OR, 2+ yrs prior auth exp. Mon-Fri 8-5 PST w/ occasional weekends. Join a welcoming team handling increased workload!
Education/Certification Required: LPN/AS RN Preferred: RN
Licensure Required:
RN, LPN, license needs to be in state of OR Preferred:
Years of experience required
Disqualifiers
Best vs. average
Performance indicators
Must haves: 2 years 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 3 must-have hard skills
Level of experience with each
Stack-ranked by importance
Candidate Review & Selection
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