Clinical Review Nurse – Prior Authorization

Job Title: Prior Authorization Nurse

Job Description

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 members benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost-effectiveness of medical care. Performs medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteria. Works with healthcare providers and the 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 the medical necessity of care for members. Escalates prior authorization requests to Medical Directors as appropriate to determine the appropriateness of care. Assists with service authorization requests for a members transfer or discharge plans to ensure a timely discharge between levels of care and facilities. Collects, documents, and maintains all members 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. Performs other duties as assigned. Complies with all policies and standards.

Hard Skills

Graduate from an Accredited School of Nursing or Bachelors degree in Nursing

2 – 4 years of related experience

Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service

Knowledge of Medicare and Medicaid regulations

Knowledge of utilization management processes

LPN – Licensed Practical Nurse – State Licensure

Soft Skills

Ability to work with healthcare providers and authorization team

Coordination skills with interdepartmental teams

Effective communication for education and feedback

Attention to detail for documenting clinical information

Analytical skills for medical necessity assessment

Job Type

This is a contract position with a duration of 26 Weeks

Work Environment

Remote

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

Diversity, Equity & Inclusion

At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

Hiring diverse talent

Maintaining an inclusive environment through persistent self-reflection

Building a culture of care, engagement, and recognition with clear outcomes

Ensuring growth opportunities for our people

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.