Review Nurse- Prior Authorization

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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. Projected start date: 12/29/2025 Shift hours: Tuesday- Saturday 8:30-5:00 PM CST 6 Month contract with extension or convert

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. Review Prior auth for standard, urgent, retro for IL Medicaid. Support UM Shared Services Review Prior auth for standard, urgent, retro for IL Medicaid. Min of 16 reviews per day Audit scores of 95% or greater shadowing preceptor Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members Performs other duties as assigned Comply with all policies and standards