Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Arizona (must be independently licensed and living in AZ)

Assignment Duration: 5 Months

Work Schedule: Standard hours (8-5), M-F, no OT required

Work Arrangement: Remote to specific state, nationally sourced, or specific time zone? Arizona (must be independently licensed and living in AZ)

Position Summary:

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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.

  
  

Background & Context:

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  This a backfill for UM specifically for med record review and to ensure compliance of CMS final rule of 7 day TAT starting 1/1/26.

  
  

Key Responsibilities:

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  Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria

  
  
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  Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care

  
  
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  Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member

  
  
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  Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care

  
  
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  Assists with service authorization requests for a member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities

  
  
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  Collects, documents, and maintains all member's clinical information in health management systems to ensure compliance with regulatory guidelines

  
  
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  Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members

  
  
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  Provides feedback on opportunities to improve the authorization review process for members

  
  
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  Performs other duties as assigned

  
  
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  Complies with all policies and standards

  
  

Qualification & Experience:

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  Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.

  
  
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  Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.

  
  
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  Knowledge of Medicare and Medicaid regulations preferred.

  
  
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  Knowledge of utilization management processes preferred.

  
  

License/Certification:

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  LPN - Licensed Practical Nurse - State Licensure required

  
  
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  For Health Net of California: RN license required

  
  
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  For Superior Health Plan: RN license required

  
  

Candidate Requirements:

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  Education/Certification Required: graduate of an accredited school of nursing or a BA degree and 2-4 years of related experience

  
  
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  Licensure Required: LCSW, LMHC, LPC, LMFT, LMHP, or RN (state OR compact state licensure)

  
  
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  Years of experience required: they should have at least 2 years in the behavioral health field; it would be a bonus if they also had some experience in utilization review

  
  

Disqualifiers / Additional qualities:

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  Disqualifiers: not independently licensed in AZ, not living in AZ

  
  
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  Additional qualities to look for: expertise reviewing BH medical charts, treatment plans, any experience in BH utilization review

  
  
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  Top 3 must-have hard skills stack-ranked by importance:

  
  
  
  
  1. 
     

     Behavioral health clinical review skills

     
     
  2. 
     

     Computer proficiency

     
     
  
  
  
  
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  Ability to multi-task and remain organized
  
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  Education/Certification	Required: graduate of an accredited school of nursing or a BA degree and 2-4 years of related experience	Preferred:
  Licensure	Required: LCSW, LMHC, LPC, LMFT, LMHP, or RN (state OR compact state licensure)	Preferred:
  Years of experience required: they should have at least 2 years in the behavioral health field; it would be a bonus if they also had some experience in utilization review Disqualifiers: not independently licensed in AZ, not living in AZ Additional qualities to look for: expertise reviewing BH medical charts, treatment plans, any experience in BH utilization review
  Top 3 must-have hard skills stack-ranked by importance	1	Behavioral health clinical review skills
  2	Computer proficiency
  3	Ability to multi-task and remain organized