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Prior Authorization Nurse - Health Plan

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Job Summary
Prior Authorization Nurse | PA Nurse | Health Plan – Las Vegas - 3 positions in – office (no remote) -Phenomenal growth has created a demand for 3 RN’s to join this national health plan. -Exceptional programs of care and quality. -Benefits are excellent and the career growth is very strong. - Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations - Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. - Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings - Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care - Educate providers on utilization and medical management processes - Provide clinical knowledge and act as a clinical resource to non-clinical team staff - Enter and maintain pertinent clinical information in various medical management systems
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Job Requirement
- Graduate from an Accredited School of Nursing.
- Bachelor’s degree in Nursing preferred.
- 2+ years of clinical nursing experience (prefer acute care) - Knowledge of healthcare and managed care preferred.
- Must be an RN
- Must be comfortable with computers and MS Office
-Licenses/Certifications: Current State LPN/LVN or RN license.
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