Clinical Review Nurse - Prior Authorization

Job Title: Clinical Review Nurse - Prior Authorization
Duration: 12 Months Contract
Location: Remote - PST and CST
Schedule: Mon - Fri (rotational weekends and holidays), Sun - Thur, Tues – Sat
Possible shifts in both PST and CST: 7am – 4pm, 8am – 5pm, 9am – 6pm, 10am – 7pm
Responsibilities:
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.
Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
Experience & Skills:
2-4 years of related experience. Prior PA experience required, experience in InterQual/ Milliman, One Note, knowledge of Utilization Management (policies/regulations)
Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills experience.
Experience in InterQual or Milliman
Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded.
Education & Licenses:
Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing
RN- Registered Nurse/LPN - Licensed Practical Nurse (NV State License Or Compact License)

Work arrangement
Yes