Nurse - Clinical Review
Core
Prospective medical necessity determinations on prior authorization requests for specialty programs including Diagnostic Imaging, Cardiology, Musculoskeletal, Physical Medicine, Sleep, Oncology, and Genetic Testing.
Role type
Clinical Review Nurse (Utilization Review)
Builds
Prior authorization decisions for health plans and specialty programs
Domain
Healthcare / Utilization Management
Required skills
Prospective utilization review, Clinical guideline application, Medical necessity determination, Clinical documentation, Provider communication, QA audit compliance
Preferred skills
Prior authorization experience, InterQual/MCG/ODG criteria knowledge, Medicare NCD/LCD knowledge, Multistate nursing license, Remote work experience
Technologies
Microsoft Office, HealthHelp review platform, Electronic Health Records (EHR)
Responsibilities
Review prior authorization requests against clinical guidelines and client policies, Identify clinical indications and missing documentation, Contact providers and members for additional information, Handle escalated and expedited cases, Participate in QA audits and calibration, Maintain productivity and quality standards
Seniority
Mid-level, hands-on IC