Pyramid Consulting, Inc
Clinical Review Nurse - Prior Authorization
Pyramid Consulting, Inc, New York, New York, United States,
Immediate need for a talented
Clinical Review Nurse - Prior Authorization.
This is a
06+months contract
opportunity with long-term potential and is located in
U.S.(Remote; Candidate needs to be in AZ).
Please review the job description below and contact me ASAP if you are interested.
Job ID: 24-36079
Pay Range: $33 - $39/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).
Note: As a part of our hiring process, along with an option to directly connect with a Recruiter or apply online, we now offer a texting option to enhance your candidate experience. Click the link below which contains the job description and a few basic questions that will help you ensure this is a good fit and expedite the shortlisting process.
https://hire.glider.ai/connect/11110772
Key Responsibilities:
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.
Key Requirements and Technology Experience:
Quality and production metrics must be met to be successful.Nurse will complete approx. 4 wks of corp training and then work 1:1 with a nurse on our team.Requires PA experience or experience in MM or UM experience.Candidate should have experience in a remote roleRed Flag-Case managers do not seem to do well in this role-manager prefers not to receive Case managers.**Ideal candidate will need to have Managed Care experience and Prior Auth!Previous PA experience and experience in MM or UM.Strong computer skills-ability to navigate multiple systemsClinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.Knowledge of Medicare and Medicaid regulations preferred.Knowledge of utilization management processes preferred.Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience.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
Our client is a leading
Healthcare Industry,
and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.
Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
Clinical Review Nurse - Prior Authorization.
This is a
06+months contract
opportunity with long-term potential and is located in
U.S.(Remote; Candidate needs to be in AZ).
Please review the job description below and contact me ASAP if you are interested.
Job ID: 24-36079
Pay Range: $33 - $39/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).
Note: As a part of our hiring process, along with an option to directly connect with a Recruiter or apply online, we now offer a texting option to enhance your candidate experience. Click the link below which contains the job description and a few basic questions that will help you ensure this is a good fit and expedite the shortlisting process.
https://hire.glider.ai/connect/11110772
Key Responsibilities:
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.
Key Requirements and Technology Experience:
Quality and production metrics must be met to be successful.Nurse will complete approx. 4 wks of corp training and then work 1:1 with a nurse on our team.Requires PA experience or experience in MM or UM experience.Candidate should have experience in a remote roleRed Flag-Case managers do not seem to do well in this role-manager prefers not to receive Case managers.**Ideal candidate will need to have Managed Care experience and Prior Auth!Previous PA experience and experience in MM or UM.Strong computer skills-ability to navigate multiple systemsClinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.Knowledge of Medicare and Medicaid regulations preferred.Knowledge of utilization management processes preferred.Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience.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
Our client is a leading
Healthcare Industry,
and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.
Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.