Clinical Review Nurse - Prior Authorization

Summary:

• Work Mode: 100% Remote, Candidates with Central Time Zone highly preferred
• Duration: 6 months, possible extension
• Shift: 8am – 5pm CST Mon – Fri, Possible holiday shifts, OT as needed (needs approval)

Responsibilities:

• Analyze 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.
• Provide recommendations to the appropriate medical team to promote quality and cost-effectiveness of medical care.
• Consolidate clinical information into an easy-to-read summary.
• Conduct medical necessity reviews with clinical information, using clinical policies and criteria.
• Collaborate with Medical Directors.
• Maintain adequate time management as the workload is high and can change throughout the day.
• Work with transplant providers at the facilities to gather clinical information.
• Ensure appropriate case management and contracting is in place for each transplant authorization.

Requirements:

• Required Education/Certification: RN degree
• Required Licensure: Current state RN license only (no LPNs)
• Years of experience required: Minimum 3 years of Utilization Management/Prior Authorization experience
• Disqualifiers: Not an RN, no PA and UM experience

Preferred Skills:

• Prior Authorization experience
• Compact Nursing License
• Transplant Medical Necessity Review experience in a Utilization Management environment or Transplant Surgical experience
• Correctly uses and interprets clinical policies and clinical review criteria to determine medical necessity
• Proficiency in MS Suite and clinical software tools to manage clinical documentation systems
• Maintains professional and courteous communication with providers and members