Prior Authorization Clinical Reviewer

Role Overview

• Prior authorization review of physical and behavioral health related services
• Utilization of clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program
• Application of critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs
• Taking provider calls related to prior authorization questions and making calls to members to inform of the coverage determination
• Gathering clinical information and applying appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment, in order to render coverage determination/recommendation/discharge planning along the continuum of care
• Utilization of clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members
• Identification of members who may benefit from care management programs and facilitation of the referral
• Identification of opportunities to promote quality effectiveness of healthcare services and benefit utilization
• Sedentary work involving periods of sitting, talking, and listening
• Performing other duties as assigned

Requirements

• 5+ years of clinical experience as RN (Registered Nurse)
• Ability to work 8-hour shifts, 5-days per week, with rotating days (including some weekends & holidays), supporting Arizona Time Zone
• Must have an active and unrestricted RN licensure in the state of Arizona or Compact RN licensure
• Previous experience in utilization management (preferred)
• Previous experience in both medical and behavioral health fields (preferred)
• Previous experience in acute care (preferred)
• Strong critical thinking and written communication skills (preferred)
• Ability to operate independently (preferred)

Benefits

• Affordable medical plan options
• 401(k) plan (including matching company contributions)
• Employee stock purchase plan
• No-cost programs for all colleagues including wellness screenings, tobacco cessation, and weight management programs
• Confidential counseling and financial coaching
• Paid time off
• Flexible work schedules
• Family leave
• Dependent care resources
• Colleague assistance programs
• Tuition assistance
• Retiree medical access