Clinical Review Nurse - Prior Authorization

MedStar Health; Columbus (OH); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Review Nurse for a remote position in Ohio. The role involves reviewing prior authorization requests, documenting medical necessity, and collaborating with a team to manage a backlog of requests. Candidates should have a nursing degree, licensure, and experience in clinical review or prior authorization. This temporary position offers the possibility of extension or conversion, with a weekday schedule.

Qualifications

• 2-4 years of related experience required.
• RN/LPN licensed professional.
• Prior Authorization experience is preferred.

Responsibilities

• Clinical review and documentation of medical requests for prior authorization.
• Remote work, Monday to Friday, 8 am-5 pm schedule.
• Timely processing of authorizations, up to 18 per day.

Skills

Computer skills

Medical knowledge

Clinical nursing experience

Critical thinking skills

Communication skills

Virtual meeting skills

Education

Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing

Nursing Licensure

Job description

Position Title: Clinical Review Nurse-Prior Authorization

Work Location: Remote, Ohio EST

Assignment Duration: 6 months (Possibility to extend or convert)

Work Schedule: 8 am-5 pm

Background & Context:

• 
  

  BHP Prior Authorization Clinical Review Nurse

  
  


• 
  

  Biweekly team huddles (virtual), and attention to emailed team instructions, proficient in toggling between multiple systems

  
  


• 
  

  Review of prior auth requests for Medicaid Line of Business.

  
  


• 
  

  To assist the PA Team reviewing a backlog of requests from providers

  
  


• 
  

  Additional business needs for support

  
  

Key Responsibilities:

• 
  

  Monday thru Friday remote work. (8a-5p)

  
  


• 
  

  Clinical review and documentation of medical request for prior authorization of medically necessary services, sitting in front of a computer for 8 hours with allowance for breaks and 1 hour lunch, biweekly team huddles (virtual), and attention to emailed team instructions, proficient in toggling between multiple systems

  
  


• 
  

  Remote work

  
  

Qualification & Experience:

• 
  

  Required: Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of related experience.

  
  


• 
  

  Required: Nursing Licensure

  
  


• 
  

  Must haves: Computer skills, medical knowledge, Care manager or clinical nursing experience, Word, Excel, Virtual meeting skills, MS outlook and EMR systems

  
  


• 
  

  Nice to haves: Prior Authorization Nurse, Medical Review Nurse, Appeals Nurse, Utilization Management or Quality Assurance Nurse experience; Critical thinking skills; good people skills and able to communicate needs; Comfortable with provider interaction

  
  


• 
  

  Disqualifiers: not having the requirements mentioned, remaining disqualifiers TBD during interview

  
  


• 
  

  Performance indicators: Quality documentation, timely processing of up to 18 authorizations per day on average, team player with positive attitude

  
  


• 
  

  Top 4 must-have hard skills (stack-ranked):

  
  
  
  
  1. 
     

     RN/LPN licensed professional

     
     
  
  
  2. 
     

     Comfortable toggling between multiple computer systems

     
     
  
  
  3. 
     

     Very agile and comfortable in fast paced environment

     
     
  
  
  4. 
     

     Prior Authorization experience