Clinical Review Nurse – Prior Authorization

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

📋 Description

• Evaluate all prior authorization requests to assess the medical necessity of services and the suitable level of care.

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

• Conduct medical necessity and clinical evaluations of authorization requests following regulatory guidelines and criteria.

• Collaborate with healthcare providers and the authorization team to guarantee a prompt review of services and requests.

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

• Refer prior authorization requests to Medical Directors as necessary.

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

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

• Educate providers and interdepartmental teams about utilization processes.

• Provide insights on potential improvements to the authorization review process.

• Carry out other assigned duties.

• Adhere to all policies and standards.

⛳️ Requirements

• Valid New York RN license.

• Availability to work Monday through Friday, from 8:30 AM to 5:00 PM ET, including a one-hour lunch break.

• Bachelor’s degree in Nursing (BSN) or a diploma from an accredited nursing school.

• 2 to 4 years of relevant experience.

• Preferred clinical knowledge and the ability to assess authorization requests and determine the medical necessity of services.

• 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 is required, along with the appropriate license; examples include Nursing, PT, and OT.

• Compliance with all policies and standards.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off in addition to holidays.

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

• Additional incentive options may be included in the overall compensation package.

• Equal opportunity employer dedicated to diversity.