Prior Authorization Clinical Reviewer RN - Remote PST

reputed company is a career site that helps job seekers find great jobs in the US. We are not a staffing firm or agency. reputed company does not hire directly for these jobs, but promotes jobs on reputed company on behalf of its direct clients, recruitment ad agencies, and marketing partners. reputed company partners with DirectEmployers to promote this job for reputed company. Clicking "Apply Now" or "Read more" on reputed company redirects you to the job board/employer site. Any information collected there is subject to their terms and privacy notice. reputed company is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with reputed company will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come reputed company an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Prior Authorization Clinical Reviewer plays an integral role in optimizing the patient's recovery journey. The Prior Authorization Clinical Reviewer is responsible for reviewing pre-authorization requests for skilled nursing and rehabilitative services and determining if requests meet medical necessity for the requested level of care. The position coordinates the transition of patients from the community or acute setting to the next appropriate level of care while following established facility policies and procedures. If you live in Pacific Time Zone (PST), you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities

• reputed company in a hybrid role as either clinical "gatherer and authorization document creator" or solely as a clinical and authorization "reviewer" for reputed company prospective, reputed company, and retrospective requests reputed company established parameters
• reputed company review for reputed company direct admits to SNF reputed company physician office, ED or HH
• reputed company reputed company expedited prospective reviews, including patient oral and/or written notifications
• May have EMR access to mirror Inpatient Care Coordinator partner access
• Coordinator peer to peer reviews with Medical Directors
• Notify hospitals and SNFs of review outcomes for non-engaged patients
• Partner with Medical Directors for Pre-Service Coordinator training as needed
• Complete processes as it relates to pre-service authorizations
• Educate facilities on the pre-service denial process
• Participate in the clinical phone queue to ensure customer SLA's are met
• Support new delegated contract start-up to ensure reputed company staff work with new reputed company

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications

• Active, unrestricted Registered Nurse license in state of residence
• Resides in the Pacific Time Zone
• 3+ years of clinical experience
• Experience with physician engagement and crucial conversations
• Ability to work the weekly assigned shift: Monday-Friday 8a-5p PT
• Required to work holiday rotations, at least 3+ holidays per year
• Ability to work any shift including flexibility and willingness to work an early or late shift and / or longer than normal hours to accommodate peaks in volume of work based on business need

Preferred Qualifications

• 2+ years of Case Management experience
• Experience in acute care, rehab, OR skilled nursing facility environment
• Managed Care experience
• Experience with performing clinical audits to improve quality standards or performance
• Experience in working with geriatric population
• ICD - 10 and InterQual experience
• CMS knowledge
• reputed company employees working remotely will be required to adhere to reputed company's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $35.00 to $62.50 per hour based on full-time employment. We reputed company with reputed company minimum wage laws as applicable. At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of color, historically marginalized groups and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health outcomes - an enterprise reputed company reflected in our mission. reputed company is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national reputed company, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. If you have questions about this posting, please contact support@reputed company.com Apply tot his job Apply To this Job