Clinical Review Nurse – Prior Authorization
Job Description:
- Analyze all prior authorization requests to determine medical necessity and appropriate level of care
- Provide recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care
- Perform medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines and criteria
- Work with healthcare providers and authorization team to ensure timely review of services and requests
- Coordinate with healthcare providers and interdepartmental teams to assess medical necessity of care
- Escalate prior authorization requests to Medical Directors as appropriate
- Assist with service authorization requests for member transfer or discharge plans
- Collect, document, and maintain member clinical information in health management systems
- Provide education to providers and interdepartmental teams on utilization processes
- Provide feedback on opportunities to improve the authorization review process
- Perform other duties as assigned
- Comply with all policies and standards
Requirements:
- Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
- 2–4 years of related experience
- LPN - Licensed Practical Nurse - State Licensure required
- Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred
- Knowledge of Medicare and Medicaid regulations preferred
- Knowledge of utilization management processes preferred
- Ability to work Monday–Friday, 8am–5pm
- Applicants must work remotely from their home anywhere within the state of Missouri
Benefits:
- Competitive pay
- Health insurance
- 401K
- Stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
