About this opportunity
SPECTRAFORCE lists this Utilization Review Nurse opportunity in washington, District of Columbia. Review the employer’s description below for duties, qualifications and application requirements.
Job description
Overview
Title: Clinical Review Nurse – Prior Authorization Review
Location: Fully Remote (PST Time Zone - WA/OR Resident)
Duration: 12-Month (Potential for Extension)
About the Role
We are seeking an experienced Clinical Review Nurse for Prior Authorization Review to join our Utilization Management team. In this role, you will conduct concurrent and prior authorization reviews, ensure timely discharges, and collaborate with medical directors, providers, and care management teams to support high-quality, cost-effective care for members.
Key Responsibilities
Performs medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteria
Works with healthcare providers and the 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 the 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 members’ 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
Qualifications
Active RN license (WA; must be in good standing)
2–4 years of Prior Authorization review and InterQual experience required
Strong documentation and communication skills
Ability to work in a high-volume environment while maintaining accuracy
Preferred Experience
Proficiency with TruCare system
Familiarity with Medicare and Medicaid
Job Details
Seniority level: Associate
Employment type: Contract
Job function: Health Care Provider
Industries: Hospitals and Health Care and Insurance
Note: This description reflects the responsibilities and requirements for the Clinical Review Nurse – Prior Authorization role as part of our utilization management team.
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Worksite address
washington, DC, 20022, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.