Spectraforce Technologies
Clinical Review Nurse - Prior Authorization
Spectraforce Technologies, Portland, Oregon, United States, 97204
Position Title
Clinical Review Nurse - Prior Authorization Work Location
Remote - Oregon Assignment Duration
3 months Work Schedule
8am-5pm PST 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 Candidate Requirements
LPN/RN in Nursing; Must have at least 2 years prior experience in Prior Authorization with an Insurance company Required: LPN/AS RN Preferred: RN Required: i.e. RN, LPN Preferred: Additional Details
Must haves: 2 years experience with PA or IP auth reviews Nice to haves: Willingness to learn; Positive attitude Performance indicators: Up to 20 auth reviews per day Top Hard Skills
Must have hard skill 1 Must have hard skill 2 Must have hard skill 3 Notes
1) Previous experience with prior auth 2) Must be a team player that works well independently 3) Must be willing to work a flexible schedule of 1 weekend a month, a few holidays per year
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Clinical Review Nurse - Prior Authorization Work Location
Remote - Oregon Assignment Duration
3 months Work Schedule
8am-5pm PST 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 Candidate Requirements
LPN/RN in Nursing; Must have at least 2 years prior experience in Prior Authorization with an Insurance company Required: LPN/AS RN Preferred: RN Required: i.e. RN, LPN Preferred: Additional Details
Must haves: 2 years experience with PA or IP auth reviews Nice to haves: Willingness to learn; Positive attitude Performance indicators: Up to 20 auth reviews per day Top Hard Skills
Must have hard skill 1 Must have hard skill 2 Must have hard skill 3 Notes
1) Previous experience with prior auth 2) Must be a team player that works well independently 3) Must be willing to work a flexible schedule of 1 weekend a month, a few holidays per year
#J-18808-Ljbffr