Clinical Review Nurse - Prior Authorization
Core
Analyzes prior authorization requests to determine medical necessity and appropriate level of care for foster care members in medical and behavioral health services.
Role type
Clinical Review Nurse (Prior Authorization)
Builds
Medical and behavioral health service authorizations for foster care members
Domain
Healthcare / Utilization Management
Required skills
Medical necessity assessment, Clinical review, Regulatory guideline interpretation, Care coordination, Discharge planning, Health management system documentation
Preferred skills
Prior authorization experience, Medicare/Medicaid regulations knowledge, Utilization management processes knowledge
Responsibilities
Perform medical necessity and clinical reviews of authorization requests, Work with healthcare providers to ensure timely review, Coordinate with interdepartmental teams to assess care, Escalate complex requests to Medical Directors, Assist with transfer or discharge plans, Collect and maintain clinical information in health systems, Provide education on utilization processes
Seniority
Mid-level, hands-on IC