Case Reviewer - NP/PA

Elevance Health•Miami, FL

2d•Remote

About The Position

The Case Reviewer - NP/PA will be responsible for conducting pre-authorization, out of network and appropriateness of tests by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers to promote the most appropriate, highest quality and effective use of required tests, medications, interventional procedures and surgeries to ensure quality member outcomes, and to optimize member benefits. This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

Requirements

Requires MA/MS from an ARC-PA (Accreditation Review Commission for the Physician Assistant) accredited program or an ACEN/CCNE (Accreditation Commission for Education in Nursing or Commission on Collegiate Nursing Education) accredited program.
Minimum of 3 years of clinical experience is also required; or any combination of education and experience which would provide an equivalent background.
Certified and current, active, unrestricted license as a Physician Assistant or APRN (Advanced Practice Registered Nurse) in applicable state(s) required.
AAPA (American Academy of PAs) and applicable state license required for Physician Assistants.
APRN and applicable state license(s) required for Nurse Practitioners.

Nice To Haves

Utilization Management experience, including complex UM reviews.
Experience with appeals, disputes and audits.

Responsibilities

Receives pre-authorization requests from front-line intake and nurse reviewers.
Conducts initial medical necessity clinical screenings.
Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review by a Medical Director.
Works closely with Medical Directors to review and make recommendations regarding medical necessity of requested tests, medications, interventional procedures and surgeries.
Documents the results of the initial clinical review and determination in the pre-certification system.
Conducts initial medical necessity review of out of network pre-authorization requests for services.
Conducts review of grievance and appeals requests to provide to Medical Directors.