Job Profile Summary Position Purpose: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 Bachelor’s 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 requiredFor Health Net of California: RN license requiredFor Superior Health Plan: RN license requiredResponsibilitiesPerforms medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteriaWorks with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized careCoordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of memberEscalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of careAssists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilitiesCollects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelinesAssists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to membersProvides feedback on opportunities to improve the authorization review process for membersPerforms other duties as assignedComplies with all policies and standards
"Fill MCD staffing needs, N-158073"2 HC - Tue - Sat sched
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At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws.This position's pay range is $7.25/hr - $80.00/hr.
