RN Clinical Review Nurse - Prior Authorization

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.

• 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

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 Fidelis Plan Only: A clinical degree as a healthcare professional is required along with the appropriate license. Examples include Nursing, PT and OT.

Pay Range: $27.02 - $48.55 per hour