Prior Authorization Nurse - Medicaid (Remote)

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Requirements:

• Requires 3 years of clinical experience.
• Requires 1 year of Medicaid/Medicare experience.
• Requires 1 year of prior authorization and member/provider notification (NOA) experience.
• Requires 1 year of experience with National Committee for Quality Assurance (NCQA) standards.
• Requires an Associate degree in Nursing.
• Requires an active, current, and unrestricted license to practice in the State of Arizona as an RN or LPN.

Responsibilities:

• Ensures the accuracy and timeliness of prior authorization requests to meet contractual requirements.
• Coordinates and manages the established preauthorization review process for pre-service requests.
• Ensures the use of nationally recognized and evidence-based standards in the completion of all pre-service reviews.
• Utilizes clinical skills, chart review, physician communication, and appropriate criteria for approval of pre-service requests; escalates requests to the medical director when criteria are not met.
• Documents review rationale to support approval and Notice of Action.
• Initiates interdepartmental coordination to ensure quality care for members.
• Participates in Quality Improvement Projects as directed.
• Engages cross-functionally in special projects as needed.
• Performs Notice of Action process and participates in policy reviews.
• Works full-time, 40 hours per week, with additional hours as needed.