Clinical Review Nurse – Prior Authorization

This is a fully remote position, open to applicants in New York.

📋 Description

• Evaluate prior authorization requests to ascertain medical necessity and the suitable level of care based on national standards, contractual obligations, and member benefit coverage.

• Offer recommendations to the relevant medical team to enhance the quality and cost-effectiveness of medical care.

• Conduct medical necessity and clinical assessments of authorization requests in line with regulatory guidelines and criteria.

• Collaborate with healthcare providers and authorization teams to ensure prompt review and authorization of care.

• Coordinate with healthcare providers and interdepartmental teams to evaluate member medical necessity for care.

• Refer prior authorization requests to Medical Directors when deemed necessary.

• Assist with service authorization requests related to member transfer or discharge plans.

• Gather, document, and maintain member clinical information within health management systems.

• Educate providers and interdepartmental teams on utilization processes.

• Provide insights on opportunities to enhance the authorization review process.

• Carry out additional duties as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Graduate from an accredited School of Nursing or possess a bachelor's degree in Nursing.

• 2–4 years of relevant experience.

• Active and unrestricted New York State Registered Nurse (RN) licensure is required.

• Availability to work Monday–Friday, 8:30 AM–5:00 PM Eastern Time, including a one-hour designated lunch break.

• Clinical knowledge and the capability to evaluate authorization requests and determine the medical necessity of services are preferred.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• For Fidelis Plan Only: A clinical degree as a healthcare professional and the appropriate license are required; examples include Nursing, PT, and OT.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K plans.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work arrangements, including remote, hybrid, field, or office schedules.

• Additional forms of incentives may be included in total compensation.