Clinical Review RN, Prior Authorization - 257287

Medix™; Rhode Island; Hybrid; USD 85,000 - 110,000; Full time

Job summary

Medix is seeking a Clinical Review RN for Prior Authorization, with 2 years of acute care experience and 1 year in prior authorization. The role supports Rhode Island utilization reviews and may require RI licensure or RI licensure readiness if based in NY.

The position involves reviewing inpatient cases, documenting medical necessity, and coordinating with physicians and analysts to ensure accurate authorizations. Onsite in Jericho or remote in RI is possible.

Qualifications

• Two years of acute clinical experience required.
• One to three years in acute care utilization review and prior authorization processes.

Responsibilities

• Conduct utilization reviews up to the appeal level for inpatient cases.
• Review admission screening across medical, surgical, psychiatric charts.
• Process authorizations, discharges, and waivers; perform concurrent/retrospective reviews.
• Collect data for clinical study objectives and collaborate with team members.
• Maintain knowledge of Medicaid payer guidelines and EMR systems.
• Provide training support and assist staff with procedures.

Skills

Acute care nursing

Utilization review

Prior authorization

Communication skills

Independent work

Education

Bachelor's degree in Nursing

Tools

EMR systems

Job description

Job Title: Clinical Review RN, Prior Authorization

Location: Cansit onsite in Jericho or remote in Rhode Island

License Requirement: If the nurse sits in Rhode Island they need an active RI license and if they sit in NY, they need to be open to getting the RI license.

Candidate Background: Must have 2 years of acute clinical experience and 1 year of experience approving Prior Authorizations. Will be reviewing ~30 cases a day for Inpatient Prior Auth regarding Psychiatric Care, NICU, Department of Corrections, and the new scope of work will include Radiology.

General Responsibilities

This individual will complete the full spectrum of activities related to Utilization or Quality reviews as assigned. They will utilize their knowledge and expertise of the review program to conduct clinical level review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process for Rhode Island.

Duties

1. Conduct utilization reviews up to and including the appeal level. This includes admission screening of medical, surgical, rehabilitation and psychiatric charts. Process authorizations, discharges, and waivers. Conduct concurrent and retrospective reviews.
2. Conduct quality and clinical study data collection reviews. This includes collaboration of annual psychiatric reports and long-term mental health reviews.
3. Act as a resource for the administrative staff in training, problem solving, and clarifying procedures.
4. Maintain thorough knowledge of Medicaid payer guidelines.
5. Utilize working knowledge of hospital electronic medical record and other information systems.
6. Participate in collaborative training specific to clinical study objectives.
7. Excellent customer service skills and telephone etiquette.
8. Other activities as may be deemed necessary.

Education and Experience (required skills)

• Baccalaureate degree in Nursing or graduate of an approved Registered Professional Nurses training program.
• A minimum of two (2) years of clinical experience in an acute care setting, preferably in medical/surgical units or specialty care areas, is required. In addition, candidates should possess one (1) to three (3) years of experience in acute care utilization review, including extensive experience with prior authorization processes.

Minimum Qualifications

• Licensed as a Registered Professional Nurse in New York State. Rhode Island State license also preferred or willing to obtain Rhode Island licensure upon onboarding.
• Knowledge and experience with electronic medical records including utilization, quality, and clinical charting.
• Ability to oversee, problem solve and work collaboratively with peers, medical, analytical, and administrative support staff.
• Excellent written and verbal skills.
• Ability to work independently with little supervision.
• Ability and desire to be flexible, innovative, and creative.

Schedule/Shift: Monday-Friday, 40 hours a week between 7am-5:30pm EST.