New

Clinical Review Nurse - Prior Authorization

Spectraforce Technologies

United States, Texas, Houston

Apr 28, 2025

Title: Clinical Review Nurse - Prior Authorization

Duration: 11+ Months

Location: Remote - anywhere in the US other than California or New York is okay

Shift: M/Th-Sat 7 am-6 pm or W-Sat 7 am-6 pm (Saturday a must)

Responsibilities:

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.
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.
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
Performing clinical reviews for our non-par authorization requests. When our team gets a request from a provider who is not contracted with Ambetter they will perform clinical reviews to determine medical necessity of service and an 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.

?License/Certification:

LPN - Licensed Practical Nurse - State Licensure required Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria

Must haves:

LPN/LVN or RN (2+ years of Nursing preferred). Microsoft Office experience, some computer knowledge. Reliable internet connection.

Nice to haves:

Prior Authorization/UM experience

Candidate Requirements
Required: Graduate from an Accredited School of Nursing	Preferred: Associate's Degree
Required: LPN/LVN or RN License	Preferred: RN License