Job Summary
A company is looking for a Clinical Review Nurse - Prior Authorization.
Key Responsibilities
- Analyze prior authorization requests to determine medical necessity and appropriate level of care
- Coordinate with healthcare providers and interdepartmental teams to ensure timely reviews and authorized care
- Document and maintain member clinical information in health management systems to ensure regulatory compliance
Required Qualifications
- Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
- 2 - 4 years of related experience preferred
- Clinical knowledge to analyze authorization requests and determine medical necessity preferred
- Knowledge of Medicare and Medicaid regulations preferred
- LPN - Licensed Practical Nurse - State Licensure required