Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Remote-sourced nationally

Assignment Duration: 7 Months Contract to Hire

Work Schedule: Monday - Friday (8 hours) (Can be EST (highly preferred), CST (second preference).

Position Summary:

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  Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.

  
  

Key Responsibilities:

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  Reviewing authorization requests

  
  
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  Utilizing evidence-based criteria and making a medically necessary determination.

  
  
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  Outreach calls to providers to request additional details if applicable.

  
  
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  They will not be completing any calls to members.

  
  

Qualification & Experience:

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  ICU, Medical Surgical background, bedside experience (Home health nurses)

  
  
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  Utilization Review (Prior Authorization)

  
  
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  Acute Care

  
  
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  Medicare experience ( Utilization Management with Medicare)

  
  
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  CCM Certification

  
  
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  ACLS Certification

  
  
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  Bachelor's with RN or RN without Bachelors is okay too

  
  
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  TruCare is the system the team uses so if they have experience it is beneficial. Microsoft Office Systems

  
  
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  RN is what the team is really looking for (If the person has an RN license without a bachelors, they are okay)

  
  
  

  Internal/External Groups with which the Candidate will interface:
  Required Skills/Experience:		Preferred Skills/ Experience:
  1.	ICU, Medical Surgical background, bedside experience (Home health nurses)	1.	Medicare experience ( Utilization Management with Medicare)
  2.	Utilization Review (Prior Authorization)	2.	CCM Certification
  3.	Acute Care	3.	ACLS Certification
  Education Requirement:	Bachelor's with RN or RN without Bachelors is okay too	Education Preferred:
  Software Skills Required:	TruCare is the system the team uses so if they have experience it is beneficial. Microsoft Office Systems
  Required Certifications:	RN is what the team is really looking for (If the person has an RN license without a bachelors, they are okay) LPN - Licensed Practical Nurse - State Licensure required Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.	Required Testing:	n/a