Clinical - Clinical Review Nurse - Prior Authorization - J00927 Clinical Review Nurse - Prior A[...]

Mindlance; Columbus (OH); Remote; USD 65,000 - 80,000; Full time

Job summary

A leading company seeks a BHP Prior Authorization Clinical Review Nurse to analyze medical necessity for authorization requests. The ideal candidate has a nursing degree, healthcare experience, and strong computer skills to enhance care management processes. This role offers a collaborative remote working environment, with responsibilities including reviewing requests and coordinating with medical teams, ensuring high-quality patient care.

Qualifications

• Licensed as an RN or LPN required.
• 2–4 years of related nursing experience preferred.
• Must have experience in care management or clinical nursing.

Responsibilities

• Perform medical necessity reviews of authorization requests.
• Coordinate care assessments with healthcare providers.
• Escalate requests to Medical Directors as needed.

Skills

Computer skills

Medical knowledge

Critical thinking

Good communication

Provider interaction skills

Education

Bachelor's degree in Nursing

Graduate from an accredited School of Nursing

Tools

EMR systems

Word

Excel

MS Outlook

Job description

Job Description: Job Profile Summary

Position Purpose:
Analyzes all prior authorization requests to determine the medical necessity of services 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-effective medical care.

Education/Experience:
Requires graduation from an accredited School of Nursing or a Bachelor's degree in Nursing with 2–4 years of related experience.
Clinical knowledge and ability to analyze authorization requests to determine medical necessity are preferred.
Knowledge of Medicare and Medicaid regulations and utilization management processes is preferred.

License/Certification:
LPN - Licensed Practical Nurse with State Licensure required.
For Health Net of California and Superior Health Plan: RN license required.

Responsibilities:

1. Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
2. Work with healthcare providers and the authorization team to ensure timely review of services and requests to ensure members receive authorized care.
3. Coordinate with healthcare providers and interdepartmental teams to assess medical necessity of care.
4. Escalate prior authorization requests to Medical Directors as appropriate.
5. Assist with service authorization requests for member transfer or discharge plans to ensure timely discharge between levels of care and facilities.
6. Maintain all member clinical information in health management systems to ensure compliance.
7. Educate providers and interdepartmental teams on utilization processes.
8. Provide feedback to improve the authorization review process.
9. Perform other duties as assigned.

Compliance with policies and standards is required.

Comments for Vendors:

EEO: Mindlance is an Equal Opportunity Employer and does not discriminate based on minority, gender, disability, religion, LGBTQI, age, or veterans status.

Story Behind the Need – Business Group & Key Projects

• Health plan or business unit
• Team culture
• Surrounding team & key projects
• Purpose of this team
• Reason for the request
• Motivators for this need
• Additional upcoming hiring needs

Position: BHP Prior Authorization Clinical Review Nurse

• Biweekly virtual team huddles, proficiency in toggling between multiple systems
• Review of prior auth requests for Medicaid
• Assist in reviewing backlog of requests from providers
• Additional business support needs

Typical Day in the Role

• Monday to Friday, remote work (8 AM - 5 PM)
• Clinical review and documentation of medical requests
• Participation in virtual team huddles

Work involves sitting at a computer for 8 hours, with breaks and a 1-hour lunch. Flexibility in schedule based on team needs is possible. No overtime expected.

Candidate Requirements

Education/Certification: Graduate from an accredited School of Nursing or Bachelor's degree in Nursing with 2–4 years of related experience. Licensure as an RN or LPN required.

Must Have: Computer skills, medical knowledge, care management or clinical nursing experience, proficiency in Word, Excel, virtual meetings, MS Outlook, and EMR systems.

Nice to Have: Experience as a Prior Authorization Nurse, Medical Review Nurse, Appeals Nurse, Utilization Management, or Quality Assurance Nurse. Critical thinking, good communication, and provider interaction skills.

Disqualifiers: Not meeting the above requirements. Specific disqualifiers to be discussed during interview.

Performance Indicators: Quality documentation, timely processing of up to 18 authorizations daily, team collaboration, positive attitude.

Top Skills: RN/LPN licensure, proficiency with multiple computer systems, adaptability in a fast-paced environment, prior authorization experience.

Interview & Onboarding: Review process within 1-2 days, one video interview, no additional testing required. Background checks as needed. No upcoming PTO planned.