Mindlance
Clinical - Clinical Review Nurse - Prior Authorization - J00927
Mindlance, Myrtle Point, Oregon, United States, 97458
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 a bachelor’s degree in nursing and 2–4 years of related experience.
Licensure / 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 prior 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 for the 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.
#J-18808-Ljbffr
Education / Experience Requires graduate from an accredited school of nursing or a bachelor’s degree in nursing and 2–4 years of related experience.
Licensure / 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 prior 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 for the 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.
#J-18808-Ljbffr