IMCS Ltd
Clinical Review Nurse - Prior Authorization (AZ only)
IMCS Ltd, New York, New York, United States,
Job Title : Clinical Review Nurse -Prior AuthorizationDuration : 6 months Contract - Potential to ExtendLocation : Arizona
(100% Remote)Shift Type : 8am-5pm.Guaranteed Hours:
40 hours per week.Pay range : $38 - $41 per hour
Duties:Review for medical necessity-based on the criteria availablePromote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.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.Reviewing clinicals for procedures against the medical policies to determine medical necessity.
Education/Experience:Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience.Previous PA experience and experience in MM or UM.Knowledge of Medicare and Medicaid regulations.Clinical knowledge and ability to analyse authorization requests and determine medical necessity of service.
License/Certification:RN License in AZ.
(100% Remote)Shift Type : 8am-5pm.Guaranteed Hours:
40 hours per week.Pay range : $38 - $41 per hour
Duties:Review for medical necessity-based on the criteria availablePromote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.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.Reviewing clinicals for procedures against the medical policies to determine medical necessity.
Education/Experience:Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience.Previous PA experience and experience in MM or UM.Knowledge of Medicare and Medicaid regulations.Clinical knowledge and ability to analyse authorization requests and determine medical necessity of service.
License/Certification:RN License in AZ.