Clinical Review Nurse - Prior Authorization

Clinical Review Nurse - Prior Authorization

BCforward is currently seeking a highly motivated Clinical Review Nurse - Prior Authorization for an opportunity in Remote (Indiana)!

Position Title: Clinical Review Nurse - Prior Authorization

Location: Remote (Indiana)

Anticipated Start Date: 11/18/2024

Please note this is the target date and is subject to change. BCforward will send official notice ahead of a confirmed start date.

Expected Duration: 3 months

Job Type: FULL TIME (>%3D30 HRS WEEKLY, [CONTRACT], [REMOTE]

Pay Range: [$40.00] - [$45.00]

Please note that actual compensation may vary within this range due to factors such as location, experience, and job responsibilities, and does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).

Requirements:

• LPN - Licensed Practical Nurse - State Licensure required
• Prior auth experience
• Knowledge of medical terminology in Medicare/Medicaid field.

Job Description:

Job Description:

Analyzes all 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 quality and cost effectiveness of medical care.

Education/Experience:
Requires Graduate from an Accredited School of Nursing or Bachelors degree in Nursing and 2 - 4 years of related experience.

Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.

License/Certification:
LPN - Licensed Practical Nurse - State Licensure required

Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
Coordinates as appropriate with healthcare 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 members transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collects, documents, and maintains all members 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 quality and cost-effective medical care to members
Provides feedback on opportunities to improve the authorization review process for members
Performs other duties as assigned

Required Skills/Experience:

Computer literacy

Prior auth experience preferred

Benefits:

BCforward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.

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About BCforward:

Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.

BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.

BCforward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.

To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.

This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.

Interested candidates please send resume in Word format Please reference job code 230438 when responding to this ad.

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