Clinical Review Nurse-with Prior Authorization

We are seeking a detail-oriented and knowledgeable Registered Nurse with Prior Authorization experience to join our healthcare team. This role is crucial in ensuring that patients receive the necessary medical services and treatments by managing the prior authorization process effectively. The ideal candidate will have a strong background in medical documentation, utilization management, and clinical documentation improvement, with experience with Medicare

Responsibilities

• · Reviewing authorization requests

· Utilizing evidence-based criteria and making a medically necessary determination.

Outreach calls to providers to request additional details if applicable

Review and analyze medical records and documentation to determine the necessity of services requested.

• Collaborate with healthcare providers to gather additional information required for prior authorization.
• Utilize Epic and other electronic health record systems for documentation review and management.
• Ensure compliance with insurance guidelines and regulations throughout the authorization process.
• Communicate effectively with patients, providers, and insurance companies regarding authorization status and requirements.
• Maintain accurate records of all authorizations, denials, and appeals.
• Medicare experience (Utilization Management with Medicare)

Experience

• · Clinical Review Nurse - Prior Authorization, utilization review nurse, prior authorization nurse
• ICU, Medical Surgical background, bedside experience (Home health nurses)
• Previous experience as a nurse or in a clinical setting is preferred.
• Familiarity with medical documentation processes, including clinical documentation improvement.
• Experience with utilization management and knowledge of medical records management.
• Proficiency in using electronic health record systems such as TruCare.
• Experience working in a Level II Trauma Center is a plus.

If you are passionate about patient care and have the skills necessary to navigate the complexities of prior authorizations, we encourage you to apply for this vital role within our organization. Utilization Review (Prior Authorization)CCM Certification

Acute Care

ACLS Certification

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