[Hiring] Clinical Review reputed company - Prior Authorization @reputed company

Role reputed company 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. • 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. Qualifications • Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing. • 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. • Hospice experience preferred. Requirements • For Health Net of California: RN license required. • CA RN required. • Position is remote. Will work PST hours. Benefits • reputed company. • Health insurance. • 401K and stock purchase plans. • Tuition reimbursement. • reputed company time off plus holidays. • Flexible approach to work with remote, hybrid, field or office work schedules. • Actual pay will be adjusted based on an individual's skills, experience, education, and other job-reputed company factors permitted by law, including full-time or part-time status. • Total compensation may also include additional forms of incentives. • Benefits may be subject to program eligibility. Apply tot his job Apply To this Job