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Clinical - Clinical Review Nurse - Prior Authorization - J00927
Job Profile Summary
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.
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.
License/Certification:
LPN - Licensed Practical Nurse - State Licensure required
For Health Net of California: RN license required
For Superior Health Plan: RN license required
Responsibilities
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
EEO:
Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.
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| Story Behind the Need | ||||||
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Medicaid and Marketplace prior authorization reviews. This position is needed to support key strategic initiatives and process improvement projects. Dedicated resources are required to ensure project deliverables are met while maintaining day-to-day operational responsibilities. Fast-paced and collaborative, focused on regulatory compliance, operational excellence, and delivering timely, accurate authorization decisions. Not at this time |
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| Typical Day in the Role | ||||||
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Review prior authorization requests within turnaround times while maintaining quality standard. 14 to 16 reviews per day. Quality score of 95% or higher Multi states with Medicaid and marketplace plans |
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| Candidate Requirements | ||||||
| Education/Certification | Required: graduated from accredited nursing program or Bachelor s degree in Nursing | Preferred: | ||||
| Licensure | Required: LPN or LVN | Preferred: RN | ||||
| Years of experience required: 2-4 years of related experience Disqualifiers: No Illinois or Compact license Additional qualities to look for: compact license or multistate licensure | ||||||
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1 | Prior experience with prior auth reviews | ||||
| 2 | organized | |||||
| 3 | Comfortable on the computer especially MS Office Suite | |||||
| Candidate Review & Selection | ||||||
|
Projected Manager Candidate Review Date: | 1-2 days post shortlisting | ||||
|
Type of Interviews: |
Teams camera on | |||||
| Required Testing or Assessment (by Vendor): | ||||||
| Next Steps | ||||||
|
Oct 30 | |||||
|
Felicia Cox | |||||
Remote
Skills:
Analysis Skills, Business Growth, Clinical Information, Clinical Nursing, Clinical Validation, Contract Requirements, Cost Effectiveness Analysis, Cross-Functional, Discharge Plans, Diversity, Health Information Management, Health Plan, Healthcare Providers, Healthcare Software, Maintain Compliance, Medicaid, Medicare, Nursing, Nursing Credentials, Patient Care, Patient Care Authorizations, Performance Metrics, Process Improvement, Quality Management, Quality of Care, Registered Nurse (RN), Regulations, Regulatory Compliance, Strategic Planning, Team Player, Time Management, Training/Teaching, Utilization Management
Mindlance
