Job Title: Clinical - Clinical Review Nurse - Prior Authorization
Duration: 12 months Contract (Potential to Extend)
Desired Start Date/End Date: 4/16/2025 - 4/15/2026
Location: Remote - Texas
Shift Type: 8am-5pm CST , Mon-Fri
Pay rate: $41 per hour
Job Duties:
- 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.
Education/Certification
Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2-4 years of experience
Licensure Required
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
Skills Required
Prior PA experience required, experience in InterQual/ Milliman, One Note, knowledge of Utilization Management (policies/regulations),
Experience Required
- 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.
