Clinical Review Nurse/Prior Authorization

Title: Clinical Review Nurse/Prior Authorization

Location: Remote - TX

Duration: 6months (CTH)

Shift: 1st

Pay rate: $38-43.00/hr

Description

Walk me through the day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD):

Reviewing authorization requests

Utilizing evidence-based criteria and making a medically necessary determination.

Outreach calls to providers to request additional details if applicable.

They will not be completing any calls to members.

Describe the performance expectations/metrics for this individual and their team:

Productivity requirement will be discussed upon hire.

Tell Me About What Their First Day Looks Like

After completing IT training there will be training with teams learning and development team (~4-week course)

Will be learning about the medical management system in which they will be working within

Shadowing with fellow team member / preceptor (RN) to ensure they are equipped with all information and materials.

What previous job titles or background work will be in this role?

Clinical Review Nurse - Prior Authorization, utilization review nurse, prior authorization nurse

What makes your team/department/culture special that you would like candidates to know?

The team is focused on ensuring that members receive the care needed.

Ensuring quality care is provided.

Collaborative team and atmosphere

What red flag(s) would cause you to immediately disqualify a candidate?

Case management experience is not what the team is looking for, even though they work with this team. Please ensure the candidate has a background in utilization review nurse, or prior authorization nurse.

Someone who was just graduated nursing school.

Required Certifications

RN is what the team is really looking for (If the person has an RN license without a bachelors, they are okay)

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.