Clinical - Clinical Review Nurse - Prior Authorization - J00927

Job Profile Summary

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 required
For Health Net of California: RN license required
For Superior Health Plan: RN license required

Responsibilities
Performs 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

EEO:

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

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"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 required For Health Net of California: RN license required For Superior Health Plan: RN license required For Fidelis Plan Only: A clinical degree as a healthcare professional is required along with the appropriate license. Examples include Nursing, PT and OT." "Performs 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
What is the purpose of this team? What is driving this need? (ex. Backfill for FTE or CW, new project, business growth) Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?		Centralized Transplant Unit conducts reviews for various transplant authorizations, across all markets and lines of business. This is to backfill a Nurse role The CTU is a small team dedicated solely to transplant reviews, and is constantly learning and researching about various types of transplants, diagnoses, etc. Reviews are spread out across all markets and follow each state and line of business specific turnaround time, meaning some can be a 14-day due date, while others can be 24 hours. We are fast-paced and high-volume but take time to appropriately train new staff and answer any questions that arise. This is the only hiring need at this time.
Typical Day in the Role
Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique?			Consolidate clinical information into an easy-to-read summary. Conduct medical necessity reviews with clinical information, using clinical policies and criteria. Collaboration with Medical Directors Maintain adequate time management as the workload is high and can change throughout the day. Work with transplant providers at the facilities to gather clinical information. Ensure appropriate case management and contracting is in place for each transplant authorization. The expectation is that this RN can handle a caseload equivalent to a FTE nurse once fully trained. This role is unique in that our team only reviews for transplant authorizations, so this is a specialized role.
Candidate Requirements
Education/Certification	Required: RN degree				Preferred: Prior Authorization experience
Licensure	Required: Current state RN license only (no LPNs)				Preferred: Compact Nursing License
Years of experience required: 3+ years of Utilization Management/ Prior Authorization experience. Disqualifiers: Additional qualities to look for: Transplant Medical Necessity Review experience in a Utilization Management environment or Transplant Surgical experience.
Top 3 must-have hard skills stack-ranked by importance			1	Correctly uses and interprets clinical policies and clinical review criteria to determine medical necessity
			2	Proficiency in MS Suite and clinical software tools to manage clinical documentation systems
			3	Maintains professional and courteous communication with providers and members
Candidate Review & Selection
Shortlisting process Candidate review & selection Interview information Onboard process and expectations			Projected Manager Candidate Review Date:			1-2 days post shortlisting
			Type of Interviews:			1 Teams (camera on)
			Required Testing or Assessment (by Vendor):			N/A
Next Steps
Do you have any upcoming PTO?			Aug 21, 24 and Sept 4
Colleagues to cc/delegate			Carmin Pruitt