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Job description
Position Title : Clinical Review Nurse - Prior Authorization
Work Location : Remote
Assignment Duration : 12 months
Work Schedule : Mon - Fri (rotational weekends and holidays) - Shifts depend on what the team needs.
Possible shifts in both PST and CST
7am - 4pm
8am - 5pm
9am - 6pm
10pm - 7pm
Work Arrangement : Remote - PST and CST (No CA and NY candidates)
Position Summary :
Routinely reviews 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. Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
Candidate Requirements
Required: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience
Preferred:
Required: Required: RN- Registered Nurse/LPN - Licensed Practical Nurse - State Licensure required Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
Preferred: NV or Compact RN license
Years of experience required: Nice to haves: 2-4 years of related experience. Prior PA experience required, experience in InterQual/ Milliman, One Note, knowledge of Utilization Management (policies/regulations), at least 1 candidate must have NV license.
Disqualifiers: California and NY candidates
Additional qualities to look for: Team player, flexible
Top 3 must-have hard skills stack-ranked by importance
1
Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills experience.
2
Experience in InterQual or Milliman
3
Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded.
Worksite address
raleigh, NC, 27601, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.