New

Clinical Review Nurse - Prior Authorization

Spectraforce Technologies

United States, North Carolina, Raleigh

500 West Peace Street (Show on map)

Jan 30, 2025

Title: Clinical Review Nurse - Prior Authorization

Duration: 12 Months

Location: Remote

Monday-Friday 8a-5p AZ time (training the same times)

some OT might be needed but generally not expected. No weekends.

Day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD):

They will work in Teams, some TruCare, CenPas, and Excel to receive and review medical records.
The providers in question will be identified by a separate team and informed of the need to submit medical records.
The reviewer will determine medical necessity of services rendered on a post-service basis.
If their schedule allows they will support the behavioral health UM inpatient team in completing medical necessity review.

Describe the performance expectations/metrics for this individual and their team:

There will be a 2-week turnaround expectation on most of these reviews.
Cross-collaboration and excellent communication is expected.
Strong attendance record expected as this reviewer will be only 1 of 2 staff that know this process.

Required Skills/Experience:		Preferred Skills/ Experience:
1.	Ability to read and interpret clinical documentation, including common acronyms	1.	Strong time management skills
2.	Strong clinical judgment and ability to use a criteria set to determine medical necessity	2.	Previous experience in UM
3.	Detail oriented	3.	Comfortable with reviewing for all levels of care in behavioral health (inpatient through outpatient)
Education Requirement:	Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience	Education Preferred:
Software Skills Required:	Microsoft Office, ability to learn other applications with training.
Required Certifications:	Required license in AZ: LPC, LCSW, LMFT, etc. or RN.	Required Testing: