Clinical Review Nurse - Prior Authorization

Job Title: Clinical Review Nurse - Prior Authorization

Location: Remote TX

Duration: 12 Months (Possibility of extension)

• Client's commitment to diversity and inclusion is a part of who we are, and we support diversity of ideas and people by fostering open communication, encouraging inclusive decision-making, and actively promoting a team composition that values diverse backgrounds and perspectives.
• Candidates will be particularly interested in the collaborative and supportive team environment, enhanced by a democratic leadership style that values each team member's input and fosters a culture of creativity and continuous improvement. This approach not only enhances job satisfaction but also drives high productivity making it an ideal setting for professionals eager to contribute meaningfully while growing their skills in a positive and inclusive workplace.

• UM is highly focused on how we can be better partners to our external stakeholders, answering the question of "how can make it easy to work with us?" Specifically, this role will impact the member and provider experience, and this nurse will be responsible for ensuring communication excellence and unbiased application of policy and state regulations to ensure best possible member health outcomes.
• Routinely reviews 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. Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
• Candidates will be particularly interested in the collaborative and supportive team environment, enhanced by a democratic leadership style that values each team member's input and fosters a culture of creativity and continuous improvement. This approach not only enhances job satisfaction but also drives high productivity making it an ideal setting for professionals eager to contribute meaningfully while growing their skills in a positive and inclusive workplace.
  
  

Education/Certification
Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience

Preferred:

Licensure
Required: 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
Preferred:

• Top 3 must-have hard skills

1
Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills experience.

2
Experience in InterQual or Milliman

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.