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Prior Authorization Nurse I
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | Sunrise, FL Sunrise, Florida |
About this job
Position Purpose: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
Educate providers on utilization and medical management processes
Provide clinical knowledge and act as a clinical resource to non-clinical team staff
Enter and maintain pertinent clinical information in various medical management systems
Education/Experience: Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred. 2 years of clinical nursing experience. Knowledge of healthcare and managed care preferred.
Licenses/Certifications: Current State LPN/LVN or RN license.
Highly Preferred:
* RN
* Utilization Management or Quality Review experience
* Case Management experience
* Med-Surg experience
* Managed Care
* Strong Computer Skills
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
Educate providers on utilization and medical management processes
Provide clinical knowledge and act as a clinical resource to non-clinical team staff
Enter and maintain pertinent clinical information in various medical management systems
Education/Experience: Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred. 2 years of clinical nursing experience. Knowledge of healthcare and managed care preferred.
Licenses/Certifications: Current State LPN/LVN or RN license.
Highly Preferred:
* RN
* Utilization Management or Quality Review experience
* Case Management experience
* Med-Surg experience
* Managed Care
* Strong Computer Skills
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.