• Job Description

  Req#: 26-00357
  
  Job Profile Summary
  
  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.
  
  Education/Experience:
  Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.
  
  Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
  Knowledge of Medicare and Medicaid regulations preferred.
  Knowledge of utilization management processes preferred.
  
  License/Certification:
  LPN - Licensed Practical Nurse - State Licensure required
  For Health Net of California: RN license required
  For Superior Health Plan: RN license required
  
  Responsibilities
  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, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines
  
  Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
  
  Provides feedback on opportunities to improve the authorization review process for members
  Performs other duties as assigned
  
  Complies with all policies and standards
  
  EEO:
  
  “Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
  
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  Job Profile Summary 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. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required For Health Net of California: RN license required For Superior Health Plan: RN license required Responsibilities 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, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members Performs other duties as assigned Complies with all policies and standards
  Story Behind the Need
  What is the purpose of this team? Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?	•Prior authorization nurse is supporting a Medicaid line of business. •Reviewing outpatient service requests to determine if they are medically necessary. •Reviewing cases in InterQual •Working with medical directors and therapists •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. •Utilization management cases
  Typical Day in the Role
  Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique?	•Fast paced environment • 36 hours 2 business day & max 7 calendar day turnaround time from start to finish with utilization management cases. (Start to finish) •Corporate training •When working in the MO LA policies and workflows it is crucial that this new hire has extensive background working with utilization management cases from start to finish.
  Candidate Requirements
  Education/Certification	Required: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience	Preferred:
  Licensure	Required: LPN, RN, or BSN Licensed Nurse and able to legally practice in LA	Preferred:
  
  

• About the company

  Mindlance is one of the largest diversity-owned staffing firms in the US . As a recruitment centric talent acquisition company, Mindlance provides Technology, Engineering, Digital / Creative / Marketing, Clinical Research, Scientific, Finance, Professional and Payroll Management staffing services to Global 1000 companies across the US, Canada and India.

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