Clinical Review Nurse - Complex Case Management and Prior-Authorization
Core
Review prior authorization requests and manage complex cases for high-risk patients to ensure medical necessity and compliance with health plan guidelines.
Role type
Senior Utilization Management Nurse (Complex Case Management & Prior Authorization) (via careerplan.io/jobs/4719908006-clinical-review-nurse-complex-case-management-and-prior-authorization-at-akidolabs)
Builds
Prior authorization determinations and evidence-based care plans for high-risk populations
Domain
US Healthcare / Utilization Management
Required skills
Prior authorization review, Complex case management, Medical necessity assessment, Clinical documentation review, Care plan development, Regulatory compliance (DMHC/CMS)
Preferred skills
EZCap system experience, Delegated MSO/health plan environment experience, Certified Case Manager (CCM)
Technologies
EZCap
Responsibilities
Review and process prior authorizations for outpatient services, procedures, and referrals; Lead interdisciplinary care management for high-risk populations; Coordinate with providers to obtain missing clinical information; Document authorization activities and decision rationale; Route denial cases to Medical Directors; Perform monthly care management outreach and medication reviews.
Seniority
Mid-Senior level, hands-on IC