Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Remote- LA

Can be sourced nationally, must have a multi-state license.

Team does work within CST standard hours; the new hire should be comfortable with these hours.

Assignment Duration: 6 Months

Work Schedule: 8am - 5pm Central Time Zone

Position Summary: 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.

Key Responsibilities:

• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
• Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
• Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member
• Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
• Assists with service authorization requests for a member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Collects, documents, and maintains all member's clinical information in health management systems to ensure compliance with regulatory guidelines
• Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
• Provides feedback on opportunities to improve the authorization review process for members
• Performs other duties as assigned
• Complies with all policies and standards

Qualification & Experience:

• Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.
• 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.
• LPN - Licensed Practical Nurse - State Licensure required
• For Health Net of California: RN license required
• For Superior Health Plan: RN license required
• Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience
• LPN, RN, or BSN Licensed Nurse and able to legally practice in LA
• Comfortable with outreach to providers (phone etiquette, strong email communications) Organized and accountable, Self-starter, 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.
• Utilization Management Review
• Outpatient Medical Setting (2-3 years)
• Comfortable with working in multiple programs