Prior Authorization Nurse

Title: Prior Authorization LVN OR RN

Schedule: Monday through Friday 8am-5pm

Pay: $33-50/hr (depending on experience)

Location: Remote after training (approx. 2-4 weeks)

Training is located in Chatsworth, CA

Please note this position is 100% remote, but training must be onsite in Chatsworth, CA, there are no exceptions for remote training. (training typically is 2-3 weeks)

Summary of Position:

The UM Prior Authorization Nurse plays a pivotal role in evaluating referrals for medical services to ensure their necessity and determine the appropriate course of action. Leveraging their expert judgment and comprehensive medical knowledge, along with adherence to clinical guidelines, they collaborate with stakeholders to facilitate optimal patient care.

Essential Duties:

• Referral Review: Employing independent judgment and extensive medical expertise, assess referral requests for medical necessity, meticulously scrutinizing patient records to ascertain eligibility for requested services while ensuring compliance with health plan and state regulations.
• Approval Recommendations: Craft detailed clinical summaries justifying the necessity of requested services, autonomously approving services when criteria are met.
• Denial Recommendations: Develop comprehensive clinical summaries outlining reasons for denial based on assessment of provided information, making recommendations for review by the Medical Director when criteria are not met.

Qualifications/Experience:

• Bachelor's or Associate Degree in Nursing (Bachelor's preferred).
• Current CA State licensure as Registered Nurse (RN) or Licensed Vocational Nurse (LVN).
• Minimum of 2 years of relevant experience, preferably in prior authorization or managed care settings.

Skills:

• Ownership and Dependability: Assumes accountability for assigned tasks, adheres to schedules, practices effective time management, and willingly accepts responsibility for outcomes.
• Attendance: Maintains exemplary attendance and reliability due to the critical nature of the department's functions.
• Attention to Detail: Possesses a keen eye for detail in analyzing medical records and adhering to clinical guidelines to ensure accuracy and quality.

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