Job Title: Utilization Review Nurse/Prior Authorization Nurse

Location: Fully Remote

Duration: 3+ months contract with highest possibility of extension

Schedule: M-F 8-5

Description:

· Responsible for the review and evaluation of clinical information and documentation.

· Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.

· Independently coordinates the clinical resolution with internal/external clinician support as required.

· Requires an RN with unrestricted active license

 

• Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations.

· Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.

· Data gathering requires navigation through multiple system applications.

· Staff may be required to contact the providers of record, vendors, or internal Clients departments to obtain additional information.-

· Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.-

· Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.-

· Commands a comprehensive knowledge of complex delegation arrangements, contracts ,clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.-Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.-

· Condenses complex information into a clear and precise clinical picture while working independently.-

· Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.

 

Experience

Minimum 3 years nursing experience with a minimum of 1 year Utilization Management Prior Authorization experience.

– Managed Care experience preferred

 

Position :

• Responsible for the review and evaluation of clinical information and documentation.
• Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required.
• Requires an RN with unrestricted active license

What days & hours will the person work in this position? List training hours, if different.

M-F8-5