What are the responsibilities and job description for the Clinical - Clinical Review Nurse - Prior Authorization position at Pacer Group?
Job Description : Position Purpose :
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 members benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
Education / Experience :
Requires Graduate from an Accredited School of Nursing or Bachelor s degree in Nursing and 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.
License / Certification :
LPN Licensed Practical Nurse State Licensure requiredPerforms 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 costeffective 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
Additional Sills :
