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Job description
Position Title: Clinical Review Nurse - Prior Authorization
Assignment Duration: 6 months; potential to extend/convert
Work Schedule: OT as needed (needs approval) / 8am - 5pm CST Mon - Fri / Possible holiday shifts
Work Arrangement: Remote-Central Time Zone preferred
Responsibilities:
Centralized Transplant Unit conducts reviews for various transplant authorizations, across all markets and lines of business.
This is to backfill a Nurse role
The CTU is a small team dedicated solely to transplant reviews, and is constantly learning and researching about various types of transplants, diagnoses, etc.
Consolidate clinical information into an easy-to-read summary.
Conduct medical necessity reviews with clinical information, using clinical policies and criteria.
Collaboration with Medical Directors
Maintain adequate time management as the workload is high and can change throughout the day.
Work with transplant providers at the facilities to gather clinical information.
Ensure appropriate case management and contracting is in place for each transplant authorization. Candidate Requirements Education/Certification Required: RN degree Preferred: Prior Authorization experience Licensure Required: Current state RN license only (no LPNs) Preferred: Compact Nursing License Years of experience required: 3+ years of Utilization Management/ Prior Authorization experience.
Disqualifiers:
Additional qualities to look for: Transplant Medical Necessity Review experience in a Utilization Management environment or Transplant Surgical experience. Top 3 must-have hard skills stack-ranked by importance
1 Correctly uses and interprets clinical policies and clinical review criteria to determine medical necessity 2 Proficiency in MS Suite and clinical software tools to manage clinical documentation systems 3 Maintains professional and courteous communication with providers and members
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.