Job Description

Job Description:

Job Title: Clinical Review Nurse - Prior Authorization

Location: Remote

Duration: 3 months (Possible Extension)

Shift Timing: 8:00am 5:00pm (Mon-Fri) (In the beginning they will not have a set weekend commitment. Once the new hire is fully trained, they are going to have to work (8) hours per day Monday Friday. (Can be EST (highly preferred), CST (second preference). (We can negotiate schedules. If someone is willing to work weekends that would be in the future. On the weekends we have a skeleton crew and generally do not schedule new staff because there is limited support.)

Walk me through the day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD):

• Reviewing authorization requests
• Utilizing evidence-based criteria and making a medically necessary determination.
• Outreach calls to providers to request additional details if applicable.
• They will not be completing any calls to members.

Describe the performance expectations/metrics for this individual and their team:

• Productivity requirement will be discussed upon hire.

Tell me about what their first day looks like:

• After completing IT training there will be training with teams learning and development team (~4-week course)
• Will be learning about the medical management system in which they will be working within
• Shadowing with fellow team member / preceptor (RN) to ensure they are equipped with all information and materials.

What previous job titles or background work will be in this role?

• Clinical Review Nurse - Prior Authorization, utilization review nurse, prior authorization nurse

What makes your team/department/culture special that you would like candidates to know?

• The team is focused on ensuring that members receive the care needed.
• Ensuring quality care is provided.
• Collaborative team and atmosphere

What red flag(s) would cause you to immediately disqualify a candidate?

• Case management experience is not what the team is looking for, even though they work with this team. Please ensure the candidate has a background in utilization review nurse, or prior authorization nurse.
• Someone who was just graduated nursing school.

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