Clinical Review Nurse-Prior Authorization-Remote

Clinical Review Nurse-Prior Authorization

Contract 2/24/2025-8/1/2025

$45/hr. 8:30-5pm

Remote IL

Job Description:
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.

Duties:
• 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

Skills:

2 – 4 years of related experience.

Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.

Prior auth review experience

Remote experience

Experience with InterQual helpful

Excel

Education/Experience:
Requires Graduate from an Accredited School of Nursing

License/Certification:
LPN - Licensed Practical Nurse -State Licensure required

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