[Hiring] Prior Authorization/Concurrent Review Nurse @Central Health
Role Description
This role involves working with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review, and other utilization management activities aimed at providing members with the right care at the right place at the right time.
ā¢ Provides daily review and evaluation of members that require hospitalization and/or procedures, providing prior authorizations and/or concurrent review.
ā¢ Mentors and trains new team members.
ā¢ Assesses services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.
ā¢ Utilizes clinical skills to review and monitor members' utilization of health care services.
ā¢ Performs telephonic reviews of inpatient hospital admissions and assists with the coordination of discharge planning needs.
ā¢ Obtains necessary information to assess a member's clinical condition and identify ongoing clinical care needs.
ā¢ Evaluates options and services required to meet the member's health needs in support and collaboration with disease management interventions.
ā¢ Performs prospective, concurrent, and retrospective review of inpatient, outpatient, ambulatory, and ancillary services requiring clinical review.
Hours of operation are Monday through Friday 8 am to 5 pm, including extended hours that may occur on weekends and/or holidays as required by State and Federal regulations.
This position is considered Remote, with occasional visits required to a Central Health office in Austin, Texas. Remote work is not available for residents of California, Colorado, New York, New Jersey, Hawaii, Maryland, Montana, Pennsylvania, Virginia, or Washington.
Qualifications
ā¢ High School Diploma or equivalent Required
ā¢ Completion of an accredited (RN) or an accredited (LVN) program Required
ā¢ One (1) year clinical practice experience Required
ā¢ Two (2) years managed care experience with utilization management and/or case management
Requirements
ā¢ Active, unrestricted State Registered Nursing license in good standing
Company Description
Apply Now
Apply Now
This role involves working with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review, and other utilization management activities aimed at providing members with the right care at the right place at the right time.
ā¢ Provides daily review and evaluation of members that require hospitalization and/or procedures, providing prior authorizations and/or concurrent review.
ā¢ Mentors and trains new team members.
ā¢ Assesses services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.
ā¢ Utilizes clinical skills to review and monitor members' utilization of health care services.
ā¢ Performs telephonic reviews of inpatient hospital admissions and assists with the coordination of discharge planning needs.
ā¢ Obtains necessary information to assess a member's clinical condition and identify ongoing clinical care needs.
ā¢ Evaluates options and services required to meet the member's health needs in support and collaboration with disease management interventions.
ā¢ Performs prospective, concurrent, and retrospective review of inpatient, outpatient, ambulatory, and ancillary services requiring clinical review.
Hours of operation are Monday through Friday 8 am to 5 pm, including extended hours that may occur on weekends and/or holidays as required by State and Federal regulations.
This position is considered Remote, with occasional visits required to a Central Health office in Austin, Texas. Remote work is not available for residents of California, Colorado, New York, New Jersey, Hawaii, Maryland, Montana, Pennsylvania, Virginia, or Washington.
Qualifications
ā¢ High School Diploma or equivalent Required
ā¢ Completion of an accredited (RN) or an accredited (LVN) program Required
ā¢ One (1) year clinical practice experience Required
ā¢ Two (2) years managed care experience with utilization management and/or case management
Requirements
ā¢ Active, unrestricted State Registered Nursing license in good standing
Company Description
Apply Now
Apply Now