[Hiring] Clinical Review Nurse @Mindlance

Role Description

Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
• 2 – 4 years of related experience
• Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred
• Knowledge of Medicare and Medicaid regulations preferred
• Knowledge of utilization management processes preferred

Requirements

• LPN - Licensed Practical Nurse - State Licensure required
• For Health Net of California: RN license required
• For Superior Health Plan: RN license required
• For Fidelis Plan Only: A clinical degree as a healthcare professional is required along with the appropriate license (e.g., Nursing, PT, OT)

Responsibilities

• 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

Candidate Requirements

• Required: RN degree
• Preferred: Prior Authorization experience
• Required: Current state RN license only (no LPNs)
• Preferred: Compact Nursing License
• Years of experience required: 3+ years of Utilization Management/Prior Authorization experience
• Disqualifiers: Transplant Medical Necessity Review experience in a Utilization Management environment or Transplant Surgical experience

Top 3 Must-Have Hard Skills

• Correctly uses and interprets clinical policies and clinical review criteria to determine medical necessity
• Proficiency in MS Suite and clinical software tools to manage clinical documentation systems
• Maintains professional and courteous communication with providers and members

EEO

“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”