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Clinical - Clinical Review Nurse - Prior Authorization

1 month ago


Charlotte, United States Axelon Full time

Location: Remote - NC
SHIFT: 8am-5pm/9am-6pm

Duration: 90 days, potential to extend

Walk me through the day to day responsibilities of this the role and a description of the project:

  • Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
  • Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
  • Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
  • Educate providers on utilization and medical management processes
  • Provide clinical knowledge and act as a clinical resource to non-clinical team staff
  • Enter and maintain pertinent clinical information in various medical management systems
Describe the performance expectations/metrics for this individual and their team:
  • Performance metric for this position post orientation is 2-2.5 reviewed authorizations/hour
What previous job titles or background work will in this role?
  • Clinical reviewer/utilization management/prior authorization nurse.
Internal/External Groups with which the Candidate will interface: Required Skills/Experience: Preferred Skills/ Experience: 1. 2+ years of clinical nursing experience 1. Knowledge of healthcare and managed care 2. 2. InterQual 3. 3. Utilization Management 4. 4. 5. 5. Education Requirement: Certificate/Associates Education Preferred: BSN Software Skills Required: Required Certifications: LPN/RN Required Testing: N/