Medical Review Nurse (RN)

Job Description:
JOB SUMMARY
The Medical Review Nurse RN reviews, authorizes, coordinates, and responds to requests for services for Client members. This position also communicates telephonically with providers and their offices, and occasionally with members. Makes decisions based on established policies and procedures, Client medical coverage guidelines, benefits, InterQual criteria, nursing knowledge. Refers cases to Client medical directors for potential denial.

Essential Functions
Review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests per established criteria meeting compliance standards and timeframes
Review all requests not approved by the non-clinical support rep to determine benefit coverage and medical necessity
Review cases and potential denials with the Medical Directors
Research requests not clearly meeting established criteria
Assist the Prior Authorization non-clinical reps with the Prior Authorization process
Coordinate and maintain complete written documentation on all prior authorization s requests.
Collaborate with other Client departments, such as Claims, UM, Quality, Disputes/Appeals, and other external vendors.
Log into phone queue to service providers
Answer inbound calls regarding authorizations within established time frame
Document contact information in electronic medical record system
Maintain productivity
Handle calls professionally
Provide accurate prior authorization information to provider offices

Job Requirements
Knowledge of medical terminology
Experience with prior authorization
Experience applying nationally recognized criteria, including InterQual
Knowledge of Medicare regulations and guidelines
Computer skills, including ability to use Microsoft Office suite
Previous experience within a call-center environment
Ability to navigate through multiple systems and screens to resolve authorization or medical review requests
Talking and typing simultaneously
Effective time management skills
Effective interpersonal and communication skills
Ability to use electronic medical record and claims systems
Problem solving abilities
Work cooperatively, positively, and collaboratively in an interdisciplinary team
Work respectfully and positively with others
Ability to manage multiple projects and prioritize work tasks to adhere to deadlines and identified time frames
Ability to think analytically and make decisions
Ability to manage large workload

Required Experience:
0-2 years related work experience

Required Education:
Highschool Diploma or GED

Required Licenses and Certifications
RN - State Licensure - Compact license acceptable

Medicare Prior Authorization (Pre-Service)
Understanding of CMS rules and regulations
Ability to toggle between multiple systems
Ability to work weekend/holiday hours on rotation

Please note - Required Licenses and Certifications
RN - State Licensure - Compact license acceptable

Feedback: We are finding that they have experience in utilization management on the provider side, rather than the insurance side, which is what we need.

This is our ideal candidate-
We are seeking a nurse with a demonstrated clinical background, excellent communication skills, and attention to detail, with experience in Utilization Management. The ideal candidate will possess critical thinking skills, proficiency in searching evidence-based clinical hierarchy criteria, including CMS guidelines, and the ability to use Microsoft software applications. Applicants should have experience with Prior Authorization from an Insurance perspective, with the ability to determine, based on criteria and submitted documentation review, whether the case meets the requirements for approval or requires a secondary review and determination by the Medical Director.
Comments for Suppliers: Please note - Required Licenses and Certifications
RN - State Licensure - Compact license acceptable