Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
Educate providers on utilization and medical management processes
Provide clinical knowledge and act as a clinical resource to non-clinical team staff
Enter and maintain pertinent clinical information in various medical management systems
Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience. Knowledge of healthcare and managed care preferred. RN highly perferred
Current State LPN/LVN or RN license.
What are the 3-4 non-negotiable requirements on this position?
State of AR RN license preferred Medicaid exp highly desired Knowledge of healthcare and managed care