Clinical Review Nurse - Prior Authorization (Hospice)

Position Purpose: Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. Key Details: Applicants for this role have the flexibility to work remotely from their home anywhere within the United States. Full-time, Monday through Friday, 8:00 a.m. to 5:00 p.m. in the employee's local time zone. Weekend coverage is required approximately once every six weeks (Saturday and Sunday), and rotating holidays with flexible scheduling provided during the week to accommodate weekend hours worked. Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, an