Clinical Review Nurse - Prior Authorization
Core
Analyzes prior authorization requests to determine medical necessity and appropriate level of care in accordance with national standards and benefit coverage.
Role type
Clinical Review Nurse (Prior Authorization)
Builds
Prior authorization decisions for member care
Domain
Healthcare / Utilization Management
Required skills
Medical necessity analysis, Clinical review, Regulatory guideline compliance, Care level determination, Discharge planning coordination, Health management system documentation
Preferred skills
Medicare/Medicaid regulations knowledge, Utilization management processes knowledge, Clinical knowledge for authorization analysis
Responsibilities
Performs medical necessity and clinical reviews of authorization requests, Works with healthcare providers to ensure timely review, Coordinates with interdepartmental teams to assess care necessity, Escalates requests to Medical Directors, Assists with transfer or discharge plans, Collects and maintains member clinical information, Provides education on utilization processes, Provides feedback on authorization review process
Seniority
Mid-level, hands-on IC
