Clinical Review Nurse - Prior Authorization

Immediate need for a talented Clinical Review Nurse - Prior Authorization. This is a 03 months contract opportunity with long-term potential and is located in Spokane, WA (Remote). Please review the job description below and contact me ASAP if you are interested.

Job ID:25-85903

Pay Range: $38 - $41/hour.  Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• Shift: Tues- Saturday 8am- 5pm PST; no OT expectations
• WA can have a compact state license.
• OR is not a compact state so they will have to have an OR license or be willing to get one.
• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
• 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
• Performs other duties as assigned
• Complies with all policies and standards
• Team leader creates the assignment and sends to the team daily- Team members are expected to complete nurse reviews on the assigned cases. Ones not meeting clinical criteria will need to be sent to the medical director for second lvl review
• Min- Except for training and day to day communication with the TP supv/Team leads

Key Requirements and Technology Experience: 

• Key skills; Prior Authorization, RN, caseload
• Must possess at least 2 years of prior Prior Authorization experience
• Candidate Requirements- LPN/RN in Nursing; Must have at least 2 years prior experience in Prior Authorization with an Insurance company
• Education/Certification Required:  LPN/AS RN   

Our client is a leading Healthcare Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

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