Job Description

Job Description:

Job Title: Clinical Review Nurse - Prior Authorization

Location: Remote - Candidate must be in AZ

Duration: 2 + Months

Working Hours: Mon Fri 830am 5pm MST

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.

Must Have:

Licensed in AZ - LPN or RN Licensed

Walk me through the day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD):
Will do medical necessity reviews for outpatient prior authorization

Describe the performance expectations/metrics for this individual and their team:
Able to process up to 15 requests per day to meet productivity

Tell me about what their first day looks like:
The first few weeks are TruCare Learning Journey, this is a strict schedule during this time. No time is to be missed.

What previous job titles or background work will be in this role?
Prior authorization, floor nursing, clinical nursing



knowledge:
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 requiredPerforms 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

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