Clinical - Clinical Review Nurse - Prior Authorization

Location:
100% Remote, time zone specific to CST.
Shift:
9-6pm CST. OT may be required but will have opportunities based on business needs. News Years Day, Thanksgiving Day and Christmas Day guaranteed holidays and off. Other holidays, based on business needs, may be asked to work. We have a rotating weekend schedule typically every 5 weeks and once training is finished, you will work Sat and Sun 8 hours each day.2 days during the week will offset that weekend expectation that you have the choice of choosing off.
Duration:
1 Year


ddress any email correspondence, read Teams message for updates, view calendar for important meetings/huddles/training for day, may have up to 10-15 calls to providers daily,

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

• Meets and Maintains productive standard (15++ Reviews/day no exceptions to the change of this expectation)
• Appropriately refers cases for secondary review as evidenced by appropriate benchmark range and quality audits- RN to MD Referral Rate
• Meets and Maintain TAT performance (100%)
• Quality reviews > /= 95% monthly
• Demonstrated comprehension of criteria application (IQ/IQC/MCG; Pass IRR annually)
• Understanding of Clinical Documentation System
• Basic Excel Skills
• Professional and courteous communication skills
Position Purpose :
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.
Education/Experience:
Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. Required Skills/Experience:
Preferred Skills/ Experience:
1. Prior authorization nurse 1. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service required. 2. InterQual 2. Knowledge of Marketplace regulations preferred. 3. Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded. 3. Knowledge of utilization management processes required. Education Requirement:
Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience Education Preferred:
n/ Software Skills Required:
InterQual Milliman, Microsoft Outlook, Basic Internet Skills Required Certifications:
Registered Nurse (RN) Required Testing:
n/