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

Job Title:

Prior Authorization Nurse Job Description The Prior Authorization Nurse plays a crucial role in analyzing authorization requests to determine the medical necessity and appropriate level of care according to national standards and contractual requirements. The position involves collaborating with medical teams to enhance the quality and cost-effectiveness of medical care. Responsibilities Analyze prior authorization requests to determine medical necessity and appropriate level of care. Provide recommendations to medical teams to promote quality and cost-effectiveness of care. Conduct medical necessity and clinical reviews to ensure regulatory compliance. Collaborate with healthcare providers and the authorization team for timely service reviews. Coordinate with healthcare providers and interdepartmental teams to assess medical necessity. Escalate prior authorization requests to Medical Directors when necessary. Assist with service authorization requests for transfers or discharges to ensure timely transitions. Document and maintain member clinical information in health management systems. Educate providers and interdepartmental teams on utilization processes to promote quality care. Provide feedback to improve the authorization review process. Perform other duties as assigned and comply with all policies and standards. Essential Skills Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing. 2-4 years of related experience in clinical settings. Current LPN – Licensed Practical Nurse State Licensure. Clinical knowledge and ability to analyze authorization requests. Familiarity with Medicare and Medicaid regulations. Understanding of utilization management processes. Additional Skills & Qualifications Registered Nurse (RN) preferred. Prior experience with clinical review preferred. Work Environment This is a 100% remote position with a collaborative team environment. Work hours are Monday to Friday, 8 AM to 5 PM, with rotating weekends. Initial training includes a four-week learning journey followed by preceptor training. Upon completion of training, the expectation is to process 15-17 authorizations per day.