Job Description

Job Description:

Job Title: Clinical Review Nurse - Prior Authorization

Location: Remote - Central Time (CST)

Duration: 6 months (Possible Extension)

Shift Timing: Monday-Friday 8a-5p CST time

Job Summary:

Walk me through the day-to-day responsibilities of this role and a description of the project (Outside of Workday JD):

• Medical Necessity Reviews using clinical criteria appropriate for the authorization
• Clinical documentation in TruCare (clinical documentation system)
• Sending second Level Reviews to Medical Directors
• Provider outreach for additional information and/or notification (letter or phone calls)
• Referrals for members with certain diagnosis (Case Management, Disease Management, etc.)

Describe the performance expectations/metrics for this individual and their team:

• Turnaround Time Compliance
• Quality Audit Scores 90%
• Productivity Metrics
• Nurse to MD referrals

Tell me about what their first day looks like:

• System set up and then instructor led virtual training

What previous job titles or background work will in this role?

• Utilization Management
• Prior Authorization

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