RN Clinical Review Nurse – Prior Authorization
Job Description:
- Analyze prior authorization requests to determine medical necessity and appropriate level of care
- Provide recommendations to the appropriate medical team to promote quality and cost-effective care
- Perform medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines and criteria
- Work with healthcare providers and the authorization team to ensure timely review of services and requests
- Coordinate with healthcare providers and interdepartmental teams to assess members’ medical necessity of care
- Escalate prior authorization requests to Medical Directors as appropriate
- Assist with service authorization requests for member transfer or discharge plans
- Collect, document, and maintain members’ clinical information in health management systems
- Provide education to providers and interdepartmental teams on utilization processes
- Provide feedback on opportunities to improve the authorization review process
- Comply with all policies and standards
- Perform other duties as assigned
Requirements:
- Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
- 2–4 years of related experience
- LPN (Licensed Practical Nurse) state licensure required
- For Fidelis Plan Only: A clinical degree as a healthcare professional is required along with the appropriate license; examples include Nursing, PT and OT
- 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
Benefits:
- Health insurance
- 401K plan
- Stock purchase plans
- Tuition reimbursement
- Paid time off
- Paid holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
- Additional forms of incentives may be included in total compensation
