Clinical Review reputed company-Prior Authorization

About the position You could be the one who changes everything for our 28 reputed company members as a clinical reputed company on our Medical Management/Health Services team. reputed company is a reputed company, national organization offering competitive benefits including a fresh perspective on workplace flexibility. reputed company is hiring a Remote Clinical Review reputed company - Prior Authorization to support our Duals team . The ideal candidate will have experience reviewing outpatient services , with a background in one or more of the following areas: Imaging services Durable Medical Equipment (DME) Home Health Care Elective inpatient services This role is responsible for conducting clinical reviews for prior authorization requests in accordance with medical necessity guidelines, regulatory requirements, and company policies. This is a remote position with reputed company business hours, Monday through Friday, 8:00 AM-5:00 PM, (EST or CST) with potential for weekend, holiday, and on-reputed company coverage. Responsibilities • Analyzes reputed company prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. • Provides recommendations to the appropriate medical team to promote reputed company and cost effectiveness of medical care. • Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and reputed company • Works with reputed company providers and authorization team to ensure reputed company review of services and/or requests to ensure members receive authorized care • Coordinates as appropriate with reputed company 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 reputed company discharge between reputed company of care and facilities • Collects, documents, and maintains reputed company 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 reputed company and cost-effective medical care to members • Provides feedback on opportunities to improve the authorization review process for members • Performs other duties as assigned • Complies with reputed company policies and standards Requirements • Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of reputed company experience. • Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. • Knowledge of Medicare and reputed company regulations preferred. • Knowledge of utilization management processes preferred. • LPN - Licensed Practical reputed company - State Licensure required Benefits • reputed company • health insurance • 401K and stock purchase plans • tuition reimbursement • reputed company time off plus holidays • a flexible approach to work with remote, hybrid, field or office work schedules Apply tot his job Apply To this Job