Prior Authorization Nurse - Remote | Wfh

We're looking for a passionate and dedicated individual to join our team as a Clinical Review Specialist. In this role, you will play a vital role in ensuring the quality and cost effectiveness of medical care in the state of GA. But this is not just any ordinary job. We offer an exciting opportunity to make a meaningful impact on people's lives while working in a collaborative and supportive environment.
Responsibilities
Conduct thorough clinical/medical necessity reviews for a wide range of cases in accordance with established policies and guidelines. Your expertise and clinical acumen will be essential in promoting optimal care outcomes.
Perform onsite reviews of emergent/urgent and continued stay requests, carefully assessing the appropriateness of care and settings. You will have the authority to approve services or collaborate with our esteemed team of Physicians and Medical Directors to make well-informed recommendations.
Utilize your clinical judgment to complete medical necessity and level of care reviews, ensuring that requested services align with the highest standards of quality and effectiveness. When necessary, refer cases to Medical Directors for further review and evaluation.
Foster effective communication and collaboration with diverse stakeholders, including providers within our extensive network and discharge planning teams. By working together, we can seamlessly coordinate member care and optimize treatment outcomes.
Take an active role in discharge planning, ensuring smooth transitions for patients and providing valuable guidance to healthcare providers on utilization and medical management processes.
Share your wealth of clinical knowledge by serving as a valuable resource for non-clinical team members, providing guidance and support whenever needed.
Maintain accurate and up-to-date clinical information in our advanced medical management systems, ensuring that all relevant details are appropriately documented and readily accessible.
Qualifications
Bachelor's degree in a healthcare-related field (e.g., nursing, healthcare administration) or equivalent experience.
Valid license or certification in a clinical field is highly preferred.
Proven experience in clinical/medical necessity reviews or a similar capacity is a strong asset.
Exceptional clinical judgment and the ability to apply guidelines and policies effectively.
Strong communication and interpersonal skills, enabling effective collaboration with diverse stakeholders.
Proficient computer skills and the ability to navigate and enter information into various medical management systems.
Join our dynamic team and contribute to improving healthcare outcomes while enjoying a fulfilling and rewarding career. Apply now to be part of our dedicated and compassionate team of healthcare professionals. Together, we can make a difference!
Employment Type: Full-Time
Salary: $ 38.00 42.00 Per Hour