Clinical – Clinical Review Nurse – Prior Authorization Clinical Review Nurse – Prior Authorization Position Available In Madison, Mississippi

Clinical

• Clinical Review Nurse
• Prior Authorization Clinical Review Nurse
• Prior Authorization#25-57299
  Ridgeland, MS
  All On-site Job Description

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 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.

Clinical 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.

License/Certification:

LPN

• Licensed Practical Nurse
• State Licensure requiredPerforms medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria 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
  Performs other duties as assigned Complies with all policies and standards
  Comments for

Vendors:

EEO:

“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of

• Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

” =========
Centene Job Description
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.

Clinical 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.

License/Certification:

LPN

• Licensed Practical Nurse
• State Licensure requiredPerforms medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria 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
  Performs other duties as assigned Complies with all policies and standards Story Behind the Need•Business Group & Key Projects Health plan or business unit
  Team culture
  Surrounding team & key projects
  Purpose of this team
  Reason for the request
  Motivators for this need
  Any additional upcoming hiring needs?

Centene Corp/Ambetter
This position is to replace Ahna Vernado
Typical Day in the Role Daily schedule & OT expectations
Typical task breakdown and rhythm
Interaction level with team
Work environment description Getting all systems set up and meeting with their preceptor. They will attend our learning journey first for about 4 weeks and then train with a preceptor on our team. Once trained, worker should be completing 15-17 authorizations per day. Compelling Story & Candidate Value Proposition What makes this role interesting?
Points about team culture
Competitive market comparison
Unique selling points
Value added or experience gained Candidate Requirements
Education/Certification Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2

• 4 years of related experience.

Preferred:

Licensure

Required:

i.e. RN

Preferred:

Years of experience required
Disqualifiers
Best vs. average
Performance indicators Must haves: 6 Months or more of RN experience.

Nice to haves:

Disqualifiers:

Performance indicators: Hitting 15-17 auths per day Best vs.

average: