Clinical - Clinical Review Nurse - Prior Authorization
2 days ago
Location: Remote - sourced nationally.
SHIFT: Monday - Friday (8 hours)
In the beginning they will not have a set weekend commitment. Once the new hire is fully trained, they are going to have to work (8) hours per day Monday - Friday. (Can be EST (highly preferred), CST (second preference). ( Client will negotiate schedules. If someone is willing to work weekends that would be in the future. On the weekends we have a skeleton crew and generally do not schedule new staff because there is limited support .)
Hiring leaders are open to working with various times. (8:00 a.m. - 5:00 p.m. can work within their time zone) Duration: Contract to Hire
Walk me through the day-to-day responsibilities of this the role and a description of the project:
- Reviewing authorization requests
- Utilizing evidence-based criteria and making a medically necessary determination.
- Outreach calls to providers to request additional details if applicable.
- They will not be completing any calls to members.
Internal/External Groups with which the Candidate will interface: Required Skills/Experience: Preferred Skills/ Experience: 1. ICU, Medical Surgical background, bedside experience (Home health nurses) 1. Medicare experience (Utilization Management with Medicare) 2. Utilization Review (Prior Authorization) 2. CCM Certification 3. cute Care 3. CLS Certification Education Requirement: Bachelors with RN or RN without Bachelors is okay too Education Preferred: 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/
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