Senior Clinical Review Nurse – Prior Authorization

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

📋 Description

• Evaluate complex and challenging prior authorization requests to assess medical necessity and the appropriate level of care.

• Analyze authorization requests and offer recommendations to the relevant medical team.

• Conduct medical necessity and clinical reviews following regulatory guidelines and criteria.

• Work in partnership with healthcare providers and authorization teams to ensure timely service reviews and authorized care.

• Refer requests to Medical Directors when deemed necessary.

• Oversee authorization requests pertaining to member transfers and discharge plans.

• Provide constructive feedback to enhance the authorization review process.

• Evaluate medical necessity alongside healthcare providers, utilization management, and care management teams.

• Collaborate with interdepartmental utilization management teams on various projects.

• Review member clinical information in health management systems for adherence to regulatory compliance.

• Educate healthcare providers and interdepartmental teams on utilization processes.

• Cultivate comprehensive knowledge of prior authorization and mentor other team members.

• Carry out other assigned responsibilities while adhering to policies and standards.

⛳️ Requirements

• Current New York State licensure as an RN, OT, or PT.

• Graduation from an accredited nursing school or possession of a bachelor's degree in nursing.

• 4–6 years of relevant experience.

• Preferred advanced clinical knowledge and the capability to analyze authorization requests to determine medical necessity.

• Preferred strong understanding of Medicare and Medicaid regulations.

• Preferred strong familiarity with utilization management processes.

• For Fidelis Plan only: clinical degree as a healthcare professional with the appropriate license, such as Nursing, PT, or OT.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plans.

• Stock purchase options.

• Tuition reimbursement programs.

• Paid time off.

• Paid holidays.

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

• Potential incentives included in overall compensation.