Mindlance
Clinical - Clinical Review Nurse - Prior Authorization - J00927
Mindlance, Brackettville, Texas, United States, 78832
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 & Skills
Ability to analyze authorization requests and determine medical necessity of service.
Knowledge of Medicare and Medicaid regulations.
Knowledge of utilization management processes.
Licensure & Certification
LPN – Licensed Practical Nurse – State licensure required.
RN license required for Health Net of California and Superior Health Plan.
Responsibilities
Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
Work with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.
Coordinate as appropriate with healthcare providers and interdepartmental teams to assess medical necessity of care of member.
Escalate prior authorization requests to Medical Directors as appropriate to determine appropriateness of care.
Assist with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
Collect, document, and maintain all member’s clinical information in health management systems to ensure compliance with regulatory guidelines.
Assist with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost‑effective medical care to members.
Provide feedback on opportunities to improve the authorization review process for members.
Perform other duties as assigned and comply with all policies and standards.
EEO Statement Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of minority, gender, disability, religion, LGBTQI, age, or veterans.
Schedule Alternate schedule: 10:00 AM – 7:00 PM.
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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 & Skills
Ability to analyze authorization requests and determine medical necessity of service.
Knowledge of Medicare and Medicaid regulations.
Knowledge of utilization management processes.
Licensure & Certification
LPN – Licensed Practical Nurse – State licensure required.
RN license required for Health Net of California and Superior Health Plan.
Responsibilities
Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
Work with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.
Coordinate as appropriate with healthcare providers and interdepartmental teams to assess medical necessity of care of member.
Escalate prior authorization requests to Medical Directors as appropriate to determine appropriateness of care.
Assist with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
Collect, document, and maintain all member’s clinical information in health management systems to ensure compliance with regulatory guidelines.
Assist with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost‑effective medical care to members.
Provide feedback on opportunities to improve the authorization review process for members.
Perform other duties as assigned and comply with all policies and standards.
EEO Statement Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of minority, gender, disability, religion, LGBTQI, age, or veterans.
Schedule Alternate schedule: 10:00 AM – 7:00 PM.
#J-18808-Ljbffr