Senior RN Clinical Review Nurse - Prior Authorization

Position Purpose

Routinely reviews more challenging 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. Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Key Responsibilities

• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
• Collaborates with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
• Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
• Manages service authorization requests for a member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Provides feedback on opportunities to improve the authorization review process for members

Requirements

• NY RN Licensure required