Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Remote- NC

Assignment Duration: 3 months

Work Schedule: Tues- Saturday 8am- 5pm EST; no OT expectations

Work Arrangement: Remote

Position Summary:

Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria

Responsibilties:

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