Clinical Review Nurse - Prior Authorization

Position Title : Clinical Review Nurse - Prior Authorization
Work Location : Remote
Assignment Duration : 12 months
Work Schedule : Mon - Fri (rotational weekends and holidays) - Shifts depend on what the team needs.
Possible shifts in both PST and CST
7am - 4pm
8am - 5pm
9am - 6pm
10pm - 7pm
Work Arrangement : Remote - PST and CST (No CA and NY candidates)

Position Summary :
Routinely reviews 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. Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Candidate Requirements Required: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience
Preferred: Required: Required: RN- Registered Nurse/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 Preferred: NV or Compact RN license Years of experience required: Nice to haves: 2-4 years of related experience. Prior PA experience required, experience in InterQual/ Milliman, One Note, knowledge of Utilization Management (policies/regulations), at least 1 candidate must have NV license.


Disqualifiers: California and NY candidates

Additional qualities to look for: Team player, flexible

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

1 Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills experience. 2 Experience in InterQual or Milliman 3 Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded.