SPECTRAFORCE
Overview
Title:
Clinical Review Nurse – Prior Authorization Review Location:
Fully Remote
(PST Time Zone - WA/OR Resident) Duration:
12-Month (Potential for Extension) About the Role
We are seeking an experienced
Clinical Review Nurse
for
Prior Authorization
Review to join our Utilization Management team. In this role, you will conduct concurrent and prior authorization reviews, ensure timely discharges, and collaborate with medical directors, providers, and care management teams to support high-quality, cost-effective care for members. Key Responsibilities
Performs medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and the 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 the 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 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 Qualifications
Active RN license
(WA; must be in good standing) 2–4 years of Prior Authorization review and InterQual experience
required Strong documentation and communication skills Ability to work in a high-volume environment while maintaining accuracy Preferred Experience
Proficiency with
TruCare
system Familiarity with
Medicare and Medicaid Job Details
Seniority level: Associate Employment type: Contract Job function: Health Care Provider Industries: Hospitals and Health Care and Insurance Note: This description reflects the responsibilities and requirements for the Clinical Review Nurse – Prior Authorization role as part of our utilization management team.
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Title:
Clinical Review Nurse – Prior Authorization Review Location:
Fully Remote
(PST Time Zone - WA/OR Resident) Duration:
12-Month (Potential for Extension) About the Role
We are seeking an experienced
Clinical Review Nurse
for
Prior Authorization
Review to join our Utilization Management team. In this role, you will conduct concurrent and prior authorization reviews, ensure timely discharges, and collaborate with medical directors, providers, and care management teams to support high-quality, cost-effective care for members. Key Responsibilities
Performs medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and the 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 the 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 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 Qualifications
Active RN license
(WA; must be in good standing) 2–4 years of Prior Authorization review and InterQual experience
required Strong documentation and communication skills Ability to work in a high-volume environment while maintaining accuracy Preferred Experience
Proficiency with
TruCare
system Familiarity with
Medicare and Medicaid Job Details
Seniority level: Associate Employment type: Contract Job function: Health Care Provider Industries: Hospitals and Health Care and Insurance Note: This description reflects the responsibilities and requirements for the Clinical Review Nurse – Prior Authorization role as part of our utilization management team.
#J-18808-Ljbffr