Clinical Review Nurse

Job Position: Clinical Review Nurse Location: Chicago, IL (Remote) Pay Rate: $42.00-$44.00/hour, based on experience Shift: 8:30-5 CST; Tues- Sat 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. Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities