Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: California (Remote)

Assignment Duration: 12 months (Possibility to convert)

Work Schedule: Training 8-5PM PST - 4-6 week course - NO TIME OFF - CAMERA ON 8-5PM PST.

NO OT, Holidays or weekends

Work Arrangement: Remote

Position Summary:

Performs medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteria

Background & Context:

• Diverse, supporting team. Key projects for turn around time
• Weekly overview team meetings CAMERA ON (professional environment and attire)
• Monthly 1on1 meet CAMERA ON
• Group chat on teams for any questions

• 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
• Required to review and process PA for all LOB for . Which includes processing letters

• Required: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.
• Required: RN CA licensure required
• Years of experience required: 2-3 years of clinical experience. UM a plus,
• 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.
• Disqualifiers: Not having a CA RN license, No long pauses in recent work history,
• Additional qualities to look for:
• 1 Critical thinking / Independent work
• 2 Organization / multitasking skills
• 3 Microsoft Office Suite product knowledge (Teams, one note, excel and word) / tech savvy