Clinical Review Nurse-Prior Authorization-Remote

Clinical Review Nurse-Prior Authorization Contract 2/24/2025-8/1/2025 $45/hr. 8:30-5pm Remote IL Job Description: 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. Duties: • 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 • 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 • Complies with all policies and standards Skills: 2 – 4 years of related experience. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. Prior auth review experience Remote experience Experience with InterQual helpful Excel Education/Experience: Requires Graduate from an Accredited School of Nursing License/Certification: LPN - Licensed Practical Nurse -State Licensure required Apply Job! For more such jobs please click here!