Job Description

Title - Clinical Review Nurse - Prior Authorization

Duration - 12 months with possible extension

Shift - 9-6pm CST. OT may be required but will have opportunities based on business needs

Location - Remote CST

Note -

News Years Day, Thanksgiving Day and Christmas Day guaranteed holidays and off. Other holidays, based on business needs, may be asked to work.

We have a rotating weekend schedule typically every 5 weeks and once training is finished, you will work Sat and Sun 8 hours each day.2 days during the week will offset that weekend expectation that you have the choice of choosing off.

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

Address any email correspondence, read Teams message for updates, view calendar for important meetings/huddles/training for day, may have up to 10-15 calls to providers daily,

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

• Meets and Maintains productive standard (15++ Reviews/day no exceptions to the change of this expectation)
• Appropriately refers cases for secondary review as evidenced by appropriate benchmark range and quality audits- RN to MD Referral Rate
• Meets and Maintain TAT performance (100%)
• Quality reviews >/= 95% monthly
• Demonstrated comprehension of criteria application (IQ/IQC/MCG; Pass IRR annually)
• Understanding of Clinical Documentation System
• Basic Excel Skills
• Professional and courteous communication skills

Required Skills/Experience:

• Prior preservice or prior authorization in Utilization Management department experience required.
• Experience in InterQual or Milliman
• Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded.

Education Requirement:

• Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience

Software Skills Required:

• InterQual Milliman, Microsoft Outlook, Basic Internet Skills

Required Certifications:

• RN

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