Graduate from an Accredited School of Nursing OR Bachelor’s degree in Nursing
Minimum 2 years of related experience
Licensure: LPN or RN
Prior Facets experience, knowledge of clinical terminology, prior office or insurance experience
Requirements:
Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care
Work with healthcare providers and authorization team to ensure timely review of services and/or requests
Coordinate with healthcare providers and interdepartmental teams to assess medical necessity of care
Escalate prior authorization requests to Medical Directors as appropriate
Job description
Summary:
Work Mode: Remote
Duration: 3 months, with potential to convert to full-time employment
Work Hours: Monday to Friday, 8:30 AM - 5:00 PM EST
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.
Provide 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.
Comply with all policies and standards.
Requirements:
Graduate from an Accredited School of Nursing OR Bachelor’s degree in Nursing.
Minimum 2 years of related experience.
Licensure: LPN or RN.
Prior Facets experience, knowledge of clinical terminology, prior office or insurance experience.
Familiarity with MCG or Interqual.
Strong communication skills, written and verbal, with phone etiquette.
Tech savvy, ability to multitask in multiple systems at once while speaking.
