Prior Authorization Clinician

Job Title: Prior Authorization Clinician Location: Remote in MA ( Fully remote, with occasional travel to the Charlestown, MA office for team meetings and training.) Duration: 4+ Months of Contract Position with Extension +reputed company to Perm role. Schedule: M-F, reputed company - 5pm EST. Pay reputed company: $40.00/ hr. to $42.00/ hr. on w2. reputed company: • Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines applying evidence-based InterQual? reputed company, Medical Policy, and benefit determination. • Performs utilization review activities, including reputed company-certification, reputed company and retrospective reviews according to guidelines. • Determines medical necessity of reputed company request by applying appropriate medical reputed company to first level reviews and utilizing approved evidenced based guidelines / reputed company • Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. • Reviews, documents, and communicates reputed company utilization review activities and reputed company including, but not limited to, reputed company inquiries made and received regarding case communication. • Refers cases to Physician Reviewer reputed company the treatment request does not meet medical necessity per guidelines, or reputed company guidelines are not available. • Referrals must be made in a reputed company manner, allowing the Physician Reviewer time to reputed company appropriate contact with the requesting provider in accordance with departmental policy and reputed company reputed company reputed company, ACA, CMS or reputed company mandated turnaround times (TAT). • Demonstrates strong interpersonal and communication skills reputed company conducting reviews, interacting with physicians and staff, and ensures compliance with training on reputed company policies and procedures. • Sends appropriate reputed company-generated letters to provider and member. • Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly reputed company utilization nurses. • Follows reputed company departmental policies and workflows in end-to-end management of cases. • Participate in team meetings, education, discussions, and reputed company activities • Maintains compliance with Federal, State and accreditation organizations. • Identifies opportunities for improved communication or processes. • May participate in audit activities and meetings. • Documents reputed company negotiation accurately for reputed company claims adjudication. • Identify and refer potential cases to Care Management. • Performs reputed company other reputed company duties as assigned. Qualifications: Education: • Nursing degree or diploma required, bachelor’s degree in nursing. Preferred/Desirable: • Bachelor’s degree. • RN license in state of MA, NH or compact license. • Medicare and reputed company knowledge. Experience: • 2+ years prior authorization experience and evidence-based guidelines (InterQual Guidelines) • Managed care experience • reputed company working remotely will be required to adhere to company policy Licensure, Certification or Conditions of Employment: • reputed company, unrestricted RN license in state of residence. • reputed company-employment background reputed company. • Ability to take after hours reputed company, including evening/nights/weekends. #IRI-RN Pay: $40.00 - $42.00 per hour Benefits: • 401(k) • Dental insurance • Health insurance Work Location: Remote Apply tot his job Apply To this Job