Clinical Review Nurse - Prior Authorization

OpTech•Detroit, MI

47d

About The Position

Analyzes all 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. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Requirements

Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.
Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.

Nice To Haves

Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.

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.
Review Prior auth for standard, urgent, retro for IL Medicaid.
Support UM Shared Services
Review Prior auth for standard, urgent, retro for IL Medicaid.
Min of 16 reviews per day
Audit scores of 95% or greater shadowing preceptor
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
Comply with all policies and standards