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Clinical Review Nurse

2 weeks ago

Phoenix, AZ, United States Spectraforce Technologies Full time

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Remote (Arizona)

Assignment Duration: 3 months (possibility of extension)

Work Arrangement: Remote

Position Summary:

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.

Key Responsibilities:

  • 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.


Qualification & 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.

  • Requires Graduate from an Accredited School of Nursing RN/LPN or Bachelor's degree in Nursing and 2 - 4 years of related experience.

  • LPN, RN, or BSN required.

  • 2-4 years experience in health authorizations, medical terminology/hipaa guidelines


Additional Information:

  • Top 3 must-have hard skills stack-ranked by importance:

    1. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred/analytical and critical thinking skills/problem solving/attention to detail

    2. Knowledge of Medicaid regulations preferred.

    3. Knowledge of utilization management processes preferred.

      Candidate Requirements

      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.

      Required: Requires Graduate from an Accredited School of Nursing RN/LPN or Bachelor's degree in Nursing and 2 - 4 years of related experience.

      Preferred:

      Required: LPN, RN, or BSN
      Preferred:

      Years of experience required: 2-4 years experience in health authorizations, medical terminology/hipaa guidelines

      Disqualifiers: NA

      Additional qualities to look for:

      • Top 3 must-have hard skills stack-ranked by importance


      1
      Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred/analytical and critical thinking skills/problem solving/attention to detail

      2
      Knowledge of Medicaid regulations preferred.

      3
      Knowledge of utilization management processes preferred.