Prior Authorization Nurse I

Company: WellCare of North Carolina
Location: Smyrna
Posted on: April 4, 2021

Job Description:

Position Purpose: 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.* 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* 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 systemsEducation/Experience: Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred. 2+ years of clinical nursing experience. Knowledge of healthcare and managed care preferred.Licenses/Certifications: Current State LPN/LVN or RN license.For North Carolina only: In addition, these individuals will conduct utilization management activities, including but not limited to prior authorization, concurrent review and retrospective review. Must reside in North Carolina, and be NC licensed nurse and/or licensed behavioral health professional in good standing.**This position is primarily remote, some office attendance required (i.e, staff meeting therefore; candidates must be located in North Carolina surroundings area)**Certification/License. RN license required. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Keywords: WellCare of North Carolina, Jacksonville , Prior Authorization Nurse I, Healthcare , Smyrna, North Carolina