Clinical Review Nurse - Prior Authorization - J00927
Location: Remote, any time zone but must work CST hours SHIFT: This is a late shift position working Monday- Friday 10a-7pm CST, rotating weekends are a MUST! Duration: 3 months (possible to extend) Target Start Date: June 15th Description: Job Profile Summary 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 members 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 Complies with all policies and standards. Candidate Requirements Education/Certification Required: Requires Graduate from an Accredited School of Nursing or Bachelors degree in Nursing Preferred: Licensure Required: RN license required- Texas or Compact Preferred: Years of experience required: 1+ years- Nursing: Required: RN license required- Texas or Compact Disqualifiers: If unable to work 10a-7p and rotation weekends- No compact license if living outside of Texas Additional qualities to look for:
- Top 3 must-have hard skills stack-ranked by importance
1 Computer skills 2 Fast paced environment 3 Critical thinking Remote Skills: Clinical Information, Clinical Nursing, Clinical Validation, Cross-Functional, Discharge Plans, Health Information Management, Healthcare Providers, Healthcare Software, Maintain Compliance, Nursing, Nursing Credentials, Patient Care, Patient Care Authorizations, Registered Nurse (RN), Regulations, Regulatory Compliance, Time Management, Training/Teaching About the Company: Axelon