Clinical Review Nurse - Prior Authorization
C
CenteneHealthcare
United States, 8:00 AM to 5:00 PMFull-TimeMiddle
Salary27.02 - 48.55 USD per hour
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Job Details
- Experience
- 2 – 4 years
Requirements
- Must reside in Oklahoma
- Licensed LPN or RN with state licensure
- Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
- 2 – 4 years of related experience
- Experience with InterQual
- Experience with utilization management
- Experience with Medicaid
- Comfortable working in a metric-driven environment
- Technologically savvy
- Excellent communication, customer service, and time-management skills
- Availability for weekend and holiday rotation
Responsibilities
- Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
- 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
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