Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Fully Remote, TX

Assignment Duration: 3 months (Extension & Contract-to hire)

Work Schedule: Training - 4-5 weeks 8AM - 5PM CST (No days off) CAMERA ON; Shift 10 AM-7PM CST - 1 hour lunch

Work Arrangement: Remote

Position Summary:

* Purpose: to perform prior authorization clinical reviews for Texas Marketplace members, additionally, will need to assist with non-par (out of network) redirections

Background & Context:

* Team currently consists of 21 prior authorization nurses performing this work, it is a team effort, collaboration with team members is available to answer any questions and training will be handled at the team level

Key Responsibilities:

* Day to day will include performing clinical reviews for prior authorization requests utilizing policies, Interqual, sending to the MD if needed. Additionally, will assist with out of network requests and redirecting to in network providers as needed.

* Performance expectations will include completing at least 20 clinical reviews per day and if assisting with out of network requests will perform 2 redirections per hour

* This role is unique as it supports Marketplace expansion for Texas

Qualification & Experience:

* Required: ADN, BSN - Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience

* Required: RN

* Years of experience required: 2-4 years

* Disqualifiers: LVN

* Additional qualities to look for: True care experience

* Top 3 must-have hard skills stack-ranked by importance

1 Adaptable to change

2 quick processing, critical thinking

3 well organized