Job Description
Clinical Review Nurse-Prior Authorization
Contract 2/24/2025-8/1/2025
$45/hr. 8:30-5pm
Remote IL
Job Description:
Analyzes all prior authorization requests to determine medical necessity of service 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 effectiveness of medical care.
Duties:
Β Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
Β Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
Β Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member
Β Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
Β Assists with service authorization requests for a memberΒs transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Β Collects, documents, and maintains all memberΒs clinical information in health management systems to ensure compliance with regulatory guidelines
Β Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
Β Provides feedback on opportunities to improve the authorization review process for members
Performs other duties as assigned
Β Complies with all policies and standards
Skills:
2 Β 4 years of related experience.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
Prior auth review experience
Remote experience
Experience with InterQual helpful
Excel
Education/Experience:
Requires Graduate from an Accredited School of Nursing
License/Certification:
LPN - Licensed Practical Nurse -State Licensure required
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