Spectraforce Technologies
Clinical Review Nurse - Prior Authorization
Spectraforce Technologies, Jacksonville, Florida, United States, 32290
Position Title: Clinical Review Nurse - Prior Authorization
Work Location: Remote - sourced nationally
Assignment Duration: 5 Months (Contract to Hire)
Work Schedule: Monday - Friday (8 hours)
Work Arrangement: Remote
Key Responsibilities
Review medical records for medical necessity.
Handle appeals and grievances.
Collaborate with medical directors and team members.
Ensure timely processing of reviews.
Maintain documentation and compliance.
Qualification & Experience
Active RN license required.
3+ years experience in utilization review or case management.
Knowledge of CMS regulations and Medicare guidelines.
Familiarity with criteria such as InterQual or Milliman.
BSN preferred.
Strong communication and analytical skills.
Required Skills / Experience Experience utilizing MCG and InterQual evidence-based criteria as well as CMS Guidelines (LCA, LCD, NCD).
Preferred Skills / Experience
ICU, Medical Surgical background, bedside experience (Home health nurses)
Medicare experience (Utilization Management with Medicare)
Utilization Review (Prior Authorization)
CCM Certification
Acute Care
ACLS Certification
Education Requirement Bachelor's with RN or RN without Bachelors is okay too, LPNs are welcomed, as well.
Software Skills Required TruCare is the system the team uses so if they have experience it is beneficial. Microsoft Office Systems.
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.
Required Testing: n / a
Position is offered by a no fee agency.
#J-18808-Ljbffr
Work Location: Remote - sourced nationally
Assignment Duration: 5 Months (Contract to Hire)
Work Schedule: Monday - Friday (8 hours)
Work Arrangement: Remote
Key Responsibilities
Review medical records for medical necessity.
Handle appeals and grievances.
Collaborate with medical directors and team members.
Ensure timely processing of reviews.
Maintain documentation and compliance.
Qualification & Experience
Active RN license required.
3+ years experience in utilization review or case management.
Knowledge of CMS regulations and Medicare guidelines.
Familiarity with criteria such as InterQual or Milliman.
BSN preferred.
Strong communication and analytical skills.
Required Skills / Experience Experience utilizing MCG and InterQual evidence-based criteria as well as CMS Guidelines (LCA, LCD, NCD).
Preferred Skills / Experience
ICU, Medical Surgical background, bedside experience (Home health nurses)
Medicare experience (Utilization Management with Medicare)
Utilization Review (Prior Authorization)
CCM Certification
Acute Care
ACLS Certification
Education Requirement Bachelor's with RN or RN without Bachelors is okay too, LPNs are welcomed, as well.
Software Skills Required TruCare is the system the team uses so if they have experience it is beneficial. Microsoft Office Systems.
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.
Required Testing: n / a
Position is offered by a no fee agency.
#J-18808-Ljbffr