Clinical Prior Authorization Nurse

Posted Date 6 days ago(10/11/2021 11:18 AM)
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Knowledge Services is seeking a Prior Authorization Nurse for a well-established client in downtown Indianapolis!  This person would work remotely until our client has determined a safe plan to return to the office.  Must have Prior Authorization experience approving & reviewing criteria for prior authorization from the insurance & payor side.


Hours are 8:00 AM - 5:00 PM

Pay: $25-29/hr based on experience


Prior Authorization Nurse Responsibilities:

  • Utilize and follow established pre-authorization review process for outpatient and inpatient services.
  • Determine medical necessity of inpatient hospitalization.
  • Utilize pre-approved criteria and guidelines to validate medical necessity of pre-service and continued stay, and appropriateness of treatment and discharge planning.
  • Perform telephonic review of acute and sub-acute services.
  • Evaluate patient medical records when determining benefit coverage including appropriateness and level of care.
  • Collaborate as directed with appropriate personnel for members with complex medical conditions.
  • Act in conjunction with appropriate team members on a daily basis to assess the inpatient census for appropriate alternative health care service needs.
  • Communicate with physicians and ancillary providers to coordinate member care.
  • Coordinate with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.
  • Maintain accurate and timely documentation in accordance with corporate policies/procedures, business, regulatory and professional accreditation standards.


Prior Authorization Nurse Qualifications:

  • Current unrestricted Indiana LPN or RN.
  • Three (3) years clinical experience.
  • Three (3) years utilization review experience.
  • Strong background in prior authorizations; Medical Assistance; ICD Coding; claims/benefits.
  • General knowledge of Medical Management practices and Managed Care principles.
  • General knowledge of regulations that are used in delivering utilization management.
  • Ability to communicate effectively both orally and in writing.
  • Demonstrated knowledge of Milliman Care Guidelines preferred.
  • Ability to use MS Word preferred.
  • Ability to evaluate medical records and other health care data.
  • Ability to establish and maintain effective and cooperative working relationships with internal/external customers.
  • Ability to effectively prioritize multiple tasks and deadlines, and accurately complete tasks within established time-frames.






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