Axelon
Clinical - Clinical Review Nurse - Prior Authorization
Axelon, St Louis, Missouri, United States
Location: 100% Remote- Time zone is specific to EST as we support Florida state members.
SHIFT: 8am-5pm est zone. OT may be required but will have opportunities based on business needs *News Years Day, Thanksgiving Day and Christmas Day guaranteed holidays and off. Other holidays, based on business needs, may be asked to work. We have a rotating weekend schedule typically every 5 weeks and once training is finished, you will work Sat and Sun 8 hours each day.2 days during the week will offset that weekend expectation that you have the choice of choosing off.
Duration: 1 Year
Job Description: Address any email correspondence, read Teams message for updates, view calendar for important meetings/huddles/training for day, may have up to 10-15 calls to providers daily, Describe the performance expectations/metrics for this individual and their team: • Meets and Maintains productive standard (15++ Reviews/day no exceptions to the change of this expectation) • Appropriately refers cases for secondary review as evidenced by appropriate benchmark range and quality audits- RN to MD Referral Rate • Meets and Maintain TAT performance (100%) • Quality reviews > /= 95% monthly • Demonstrated comprehension of criteria application (IQ/IQC/MCG; Pass IRR annually) • Understanding of Clinical Documentation System • Basic Excel Skills • Professional and courteous communication skills.
What previous job titles or background work will be in this role?
Prior PA experience required, experience in InterQual/ Milliman, One Note, Knowledge of Utilization Management (policies/regulations), Previous roles where nurse worked independently, fast paced, detail oriented documentation. Previous Job Titles: Clinical Review Nurse, Pre Service Nurse, Prior Authorization Nurse, Charge Nurse, Director of Nursing, Leadership Roles in Nursing Position Purpose:
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.
Education/Experience : Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. Required Skills/Experience: Preferred Skills/ Experience: 1. Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills.expereience. 1. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service required. 2. Experience in InterQual or Milliman 2. Knowledge of Medicare and Medicaid regulations preferred. 3. Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded. 3. Knowledge of utilization management processes required. Education Requirement: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience Education Preferred: n/ Software Skills Required: InterQual Milliman, Microsoft Outlook, Basic Internet Skills Required Certifications: 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 criteri Required Testing: n/
SHIFT: 8am-5pm est zone. OT may be required but will have opportunities based on business needs *News Years Day, Thanksgiving Day and Christmas Day guaranteed holidays and off. Other holidays, based on business needs, may be asked to work. We have a rotating weekend schedule typically every 5 weeks and once training is finished, you will work Sat and Sun 8 hours each day.2 days during the week will offset that weekend expectation that you have the choice of choosing off.
Duration: 1 Year
Job Description: Address any email correspondence, read Teams message for updates, view calendar for important meetings/huddles/training for day, may have up to 10-15 calls to providers daily, Describe the performance expectations/metrics for this individual and their team: • Meets and Maintains productive standard (15++ Reviews/day no exceptions to the change of this expectation) • Appropriately refers cases for secondary review as evidenced by appropriate benchmark range and quality audits- RN to MD Referral Rate • Meets and Maintain TAT performance (100%) • Quality reviews > /= 95% monthly • Demonstrated comprehension of criteria application (IQ/IQC/MCG; Pass IRR annually) • Understanding of Clinical Documentation System • Basic Excel Skills • Professional and courteous communication skills.
What previous job titles or background work will be in this role?
Prior PA experience required, experience in InterQual/ Milliman, One Note, Knowledge of Utilization Management (policies/regulations), Previous roles where nurse worked independently, fast paced, detail oriented documentation. Previous Job Titles: Clinical Review Nurse, Pre Service Nurse, Prior Authorization Nurse, Charge Nurse, Director of Nursing, Leadership Roles in Nursing Position Purpose:
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.
Education/Experience : Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. Required Skills/Experience: Preferred Skills/ Experience: 1. Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills.expereience. 1. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service required. 2. Experience in InterQual or Milliman 2. Knowledge of Medicare and Medicaid regulations preferred. 3. Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded. 3. Knowledge of utilization management processes required. Education Requirement: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience Education Preferred: n/ Software Skills Required: InterQual Milliman, Microsoft Outlook, Basic Internet Skills Required Certifications: 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 criteri Required Testing: n/