Clinical Review Nurse – Prior Authorization

Clinical Review Nurse – Prior Authorization

Requirements

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
• 2 – 4 years of related experience
• RN or LVN or LPN State Licensure required

Responsibilities

• Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care
• Performs medical necessity and clinical reviews of authorization requests
• Works with healthcare providers and authorization team to ensure timely review of services
• Coordinates with healthcare providers and interdepartmental teams to assess medical necessity of care
• Escalates prior authorization requests to Medical Directors as appropriate
• Assists with service authorization requests for a member’s transfer or discharge plans
• Collects, documents, and maintains all member’s clinical information in health management systems
• Assists with providing education to providers and/or interdepartmental teams on utilization processes
• Provides feedback on opportunities to improve the authorization review process
• Performs other duties as assigned
• Complies with all policies and standards

Preferred Qualifications

• Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred
• Knowledge of Medicare and Medicaid regulations preferred
• Knowledge of utilization management processes preferred