Clinical Review Nurse - Prior Authorization

Overview

Review prior authorization requests to assess medical necessity and ensure appropriate care.

Key Responsibilities

• medical review
• authorization
• clinical documentation
• health systems
• provider education
• care coordination

Tasks

-Collaborate with healthcare providers and the authorization team to ensure timely review of services and requests, ensuring members receive authorized care. -Offer feedback on opportunities to improve the authorization review process for members. -Coordinate with healthcare providers and interdepartmental teams to assess the medical necessity of member care. -Escalate prior authorization requests to Medical Directors as needed to determine the appropriateness of care. -Provide education to providers and interdepartmental teams on utilization processes to promote high-quality and cost-effective medical care. -Assist with service authorization requests for a member’s transfer or discharge plans to ensure timely discharge between levels of care and facilities. -Collect, document, and maintain all members’ clinical information in health management systems to ensure compliance with regulatory guidelines. -Perform medical necessity and clinical reviews of authorization requests to determine the appropriateness of care in accordance with regulatory guidelines and criteria.

Requirements

• clinical
• nursing degree
• lpn
• medicare
• medicaid
• utilization management

What You Bring

-Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. -Graduate from an Accredited School of Nursing or a Bachelor's degree in Nursing with 2 – 4 years of related experience. -Knowledge of Medicare and Medicaid regulations preferred. -Licensed Practical Nurse (LPN) - State Licensure required. -Familiarity with utilization management processes preferred.

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Benefits

-Employee Assistance Program -Short and long-term disability -Time Off/Leave (PTO, Vacation or Sick Leave) -Medical, dental & vision -Life Insurance (Voluntary Life & AD&D for the employee and dependents) -Critical Illness, Accident, and Hospital -Health Spending Account (HSA) -Transportation benefits -401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available

About Actalent

-Born in July 2021 by merging Aerotek’s engineering & sciences arm with EASi, Actalent emerged as a focused engineering-and-science partner. -Backed by Allegis Group, it drives scale and speed to market via contract, managed, and technical services. -Headquartered in Maryland with global reach, it deploys specialized teams across North America, Europe, and APAC on Fortune 500 projects. -Typical engagements span EV design, vaccine development, lab services, clinical research, and infrastructure systems. -Expertise covers a wide spectrum: aerospace, defense, healthcare, manufacturing, software systems, environmental and civil engineering.

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