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-NC
Assignment Duration: 3 months
Work Schedule: Monday- Friday 8am-5pm EST
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.
LPN - Licensed Practical Nurse - State Licensure required
Education/Certification Required: Graduate from an Accredited School of Nursing
or
Bachelor's degree in Nursing
and
2 - 4 years of related experience. Preferred:
Licensure Required:
LPN - Licensed Practical Nurse - State Licensure required Preferred: RN
Years of experience required
Disqualifiers
Best vs. average
Performance indicators
Must haves: 2 years experience with PA auth reviews
Nice to haves: Previous experience with NC State Criteria/ InterQual Criteria
Disqualifiers:
Performance indicators: 15 Auths reviews per day
Top 3 must-have hard skills
Level of experience with each
Stack-ranked by importance
Candidate Review & Selection
1 Must have 2 years prior exp in PA or IP with an insurance company
2 Must be a team player
3 Must be willing to work an alt schedule of Monday - Friday
Work Location: Remote-NC
Assignment Duration: 3 months
Work Schedule: Monday- Friday 8am-5pm EST
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.
LPN - Licensed Practical Nurse - State Licensure required
Education/Certification Required: Graduate from an Accredited School of Nursing
or
Bachelor's degree in Nursing
and
2 - 4 years of related experience. Preferred:
Licensure Required:
LPN - Licensed Practical Nurse - State Licensure required Preferred: RN
Years of experience required
Disqualifiers
Best vs. average
Performance indicators
Must haves: 2 years experience with PA auth reviews
Nice to haves: Previous experience with NC State Criteria/ InterQual Criteria
Disqualifiers:
Performance indicators: 15 Auths reviews per day
Top 3 must-have hard skills
Level of experience with each
Stack-ranked by importance
Candidate Review & Selection
1 Must have 2 years prior exp in PA or IP with an insurance company
2 Must be a team player
3 Must be willing to work an alt schedule of Monday - Friday