Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Fully Remote, TX (Central Time Zone Preferred)

Assignment Duration: 3 months (Potential to extend and/or convert)

Work Schedule: 8AM-5PM CST (1-hour lunch, no days off during training)

Work Arrangement: Remote

Position Summary:

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  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:

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  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

  
  
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  A total of 10 temps will be hired (5 under Natalie 154880-1 10 AM-7PM CST, 5 under Molly 154878-1 8AM-5PM CST), no additional temps anticipated at this time

  
  

Key Responsibilities:

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  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

  
  
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  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

  
  
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  This role is unique as it supports Marketplace expansion for Texas

  
  

Qualification & Experience:

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

  
  
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  Required: RN

  
  
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  Disqualifiers: LVN

  
  
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  Additional qualities to look for: True care experience

  
  
  
  
  1. 
     

     Adaptable to change

     
     
  2. 
     

     Quick processing, critical thinking

     
     
  3. 
     

     Well organized