Clinical Review Nurse - Prior Authorization

Spectraforce Technologies; Raleigh (NC); Remote; USD 65,000 - 80,000; Full time

Job summary

A leading healthcare company is seeking a Clinical Review Nurse for Prior Authorization. This remote position requires analyzing authorization requests to ensure medical necessity and collaborating with healthcare teams to enhance patient care. Ideal candidates will have a nursing degree and relevant experience, with strong analytical and communication skills. Join us to make a significant impact on healthcare quality and efficiency.

Qualifications

• 2-4 years of related experience in nursing.
• Minimum 6 months of RN experience required.

Responsibilities

• Perform medical necessity and clinical reviews of authorization requests.
• Collaborate with healthcare providers for timely review.
• Provide education on utilization processes.

Skills

Clinical Knowledge

Analytical Skills

Communication

Education

Bachelor's degree in Nursing

Tools

Microsoft Office

Job description

Title: Clinical Review Nurse - Prior Authorization

Location: Remote

Duration: 12 Months

Shift: 8a-5p CST M-F rotating weekends

Job Description:

Analyzes all prior authorization requests to determine the medical necessity of services and the appropriate level of care in accordance with national standards, contractual requirements, and member benefit coverage. Provides recommendations to the medical team to promote quality and cost-effective medical care.

Education/Experience:

• Graduate from an accredited School of Nursing or Bachelor's degree in Nursing with 2-4 years of related experience.
• Clinical knowledge and ability to analyze authorization requests and determine medical necessity preferred.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

License/Certification:

• Licensed Practical Nurse (LPN) with state licensure required.

Responsibilities:

• Perform medical necessity and clinical reviews of authorization requests to determine appropriateness of care.
• Collaborate with healthcare providers and the authorization team to ensure timely review and member care.
• Coordinate with healthcare providers and interdepartmental teams to assess medical necessity.
• Escalate requests to Medical Directors as appropriate.
• Assist with service authorization for member transfers or discharges to ensure timely care.
• Maintain all clinical information in health management systems for compliance.
• Provide education to providers and teams on utilization processes.
• Offer feedback to improve the authorization review process.
• Perform other duties as assigned and comply with policies and standards.

Candidate Requirements:

Education/Certification:

Graduate from an accredited School of Nursing or Bachelor's degree in Nursing with 2-4 years of related experience. Preferred: RN licensure.

Experience:

Minimum 6 months of RN experience required. Performance indicator: 15-17 authorizations per day.

Hard Skills:

• Proficiency in Microsoft Office