Spectraforce Technologies
Clinical Review Nurse - Prior Authorization
Spectraforce Technologies, Raleigh, North Carolina, United States, 27601
Title: Clinical Review Nurse - Prior Authorization Duration: 12 Months Location: Remote
Monday-Friday 8a-5p AZ time (training the same times) some OT might be needed but generally not expected. No weekends.Day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD): They will work in Teams, some TruCare, CenPas, and Excel to receive and review medical records. The providers in question will be identified by a separate team and informed of the need to submit medical records. The reviewer will determine medical necessity of services rendered on a post-service basis. If their schedule allows they will support the behavioral health UM inpatient team in completing medical necessity review.
Describe the performance expectations/metrics for this individual and their team: There will be a 2-week turnaround expectation on most of these reviews. Cross-collaboration and excellent communication is expected. Strong attendance record expected as this reviewer will be only 1 of 2 staff that know this process.
Required Skills/Experience:
Preferred Skills/ Experience:1.
Ability to read and interpret clinical documentation, including common acronyms
1.
Strong time management skills2.
Strong clinical judgment and ability to use a criteria set to determine medical necessity
2.
Previous experience in UM3.
Detail oriented
3.
Comfortable with reviewing for all levels of care in behavioral health (inpatient through outpatient)Education Requirement:
Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience
Education Preferred:Software Skills Required:
Microsoft Office, ability to learn other applications with training.Required Certifications:
Required license in AZ: LPC, LCSW, LMFT, etc. or RN.Required Testing:
Monday-Friday 8a-5p AZ time (training the same times) some OT might be needed but generally not expected. No weekends.Day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD): They will work in Teams, some TruCare, CenPas, and Excel to receive and review medical records. The providers in question will be identified by a separate team and informed of the need to submit medical records. The reviewer will determine medical necessity of services rendered on a post-service basis. If their schedule allows they will support the behavioral health UM inpatient team in completing medical necessity review.
Describe the performance expectations/metrics for this individual and their team: There will be a 2-week turnaround expectation on most of these reviews. Cross-collaboration and excellent communication is expected. Strong attendance record expected as this reviewer will be only 1 of 2 staff that know this process.
Required Skills/Experience:
Preferred Skills/ Experience:1.
Ability to read and interpret clinical documentation, including common acronyms
1.
Strong time management skills2.
Strong clinical judgment and ability to use a criteria set to determine medical necessity
2.
Previous experience in UM3.
Detail oriented
3.
Comfortable with reviewing for all levels of care in behavioral health (inpatient through outpatient)Education Requirement:
Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience
Education Preferred:Software Skills Required:
Microsoft Office, ability to learn other applications with training.Required Certifications:
Required license in AZ: LPC, LCSW, LMFT, etc. or RN.Required Testing: