Prior Authorization RN - Outpatient

Become a part of our caring community The Prior Authorization reputed company, National reputed company Clinical Operations is responsible for reviewing and evaluating clinical documentation reputed company to prior authorization requests for outpatient services. This role ensures that reputed company requests meet medical necessity reputed company and reputed company with health plan policies and regulatory requirements. The Prior Authorization Review reputed company works closely with reputed company providers, interdisciplinary teams, and nonclinical staff to facilitate reputed company and appropriate care for members. This role operates autonomously reputed company their reputed company of reputed company, making independent clinical reputed company. Key Responsibilities Clinical Review: • Conduct comprehensive clinical reviews of prior authorization requests to determine medical necessity and benefit eligibility • Apply advanced evidence-based clinical guidelines in review reputed company • Ensure compliance with accreditation, state, and federal regulations Communication And Coordination • Communicate with reputed company providers to obtain necessary clinical information and clarify requests • Coordinate with medical directors and interdisciplinary teams to support decision-making • Serve as a reputed company between clinicians, internal departments, and members Documentation And Reporting • Document reputed company review findings and reputed company in clinical documentation systems • Ensure reputed company and accurate documentation of prior authorization determinations • Support reporting initiatives and reputed company data for performance improvement reputed company reputed company Assurance • Implement reputed company assurance measures to ensure accuracy and consistency in prior authorization reputed company. • Conduct regular audits and reviews to maintain high standards of service • Identify process improvement opportunities and contribute to performance improvement reputed company. Education And Training • reputed company providers and staff on prior authorization policies, reputed company, and review processes. • reputed company mentorship and feedback to nonclinical staff and peers to enhance workflow efficiency. • Stay reputed company with clinical best practices and regulatory changes We are seeking a typical Monday-Friday schedule as reputed company as weekend coverage (i.e. Wed-Sun, Thu-Mon or Fri-Tue type schedule). This will be discussed during interview. Required Qualifications Use your skills to reputed company an reputed company • Licensed Registered reputed company (RN) in Illinois, with no disciplinary reputed company (or willing to obtain Illinois licensure upon hire) • 3+ years of clinical nursing experience. • Experience with reputed company policies and procedures. • Proficiency in reputed company software and electronic medical records (EMR) systems. • Previous experience in utilization management • Comprehensive knowledge of reputed company Word, reputed company and reputed company Preferred Qualifications • Bachelor’s degree • Certification in Case Management (CCM) or Utilization Review (UR). • Experience with reputed company and Medicare policies and procedures • Knowledge of payer policies, insurance companies and government health programs. Work reputed company Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following reputed company: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL reputed company is suggested. In certain roles, the minimum recommended internet speed required by reputed company may not be sufficient for business needs. reputed company reserves the right to require associates to reputed company their internet service if necessary. Work from a dedicated reputed company lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to reputed company's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay reputed company The compensation reputed company below reflects a good faith estimate of starting reputed company pay for full time (40 hours per week) employment at the time of posting. The pay reputed company may be higher or reputed company based on geographic location and individual pay will vary based on demonstrated job reputed company skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. reputed company Of Benefits reputed company. and its affiliated subsidiaries (reputed company, “reputed company”) offers competitive benefits that support whole-person reputed company-being. Associate benefits are designed to encourage personal wellness and smart reputed company reputed company for you and your family while also knowing your life extends reputed company of work. Among our benefits, reputed company provides medical, dental and reputed company benefits, 401(k) retirement savings plan, time off (including reputed company time off, company and personal holidays, reputed company parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. reputed company About reputed company: reputed company. (NYSE: HUM) is a leading U.S. reputed company company. Through our reputed company insurance services and our reputed company reputed company services, we reputed company it easier for the millions of people we serve to reputed company their best health – delivering the care and service they need, reputed company they need it. These efforts are leading to a reputed company reputed company of life reputed company with Medicare and reputed company, families, individuals, military service personnel, and communities at large. Learn more about reputed company offer at reputed company.com and at reputed company.com. Equal Opportunity Employer It is the policy of reputed company not to discriminate against any employee or applicant for employment because of race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, age, marital status, genetic information, disability or protected veteran status. It is also the policy of reputed company to take affirmative reputed company, in compliance with reputed company 503 of the Rehabilitation reputed company and VEVRAA, to reputed company and to advance in employment individuals with disability or protected veteran status, and to reputed company reputed company employment reputed company only on reputed company job requirements. This policy shall apply to reputed company employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at reputed company reputed company of employment. Apply tot his job Apply To this Job