Job Description: Analyze all prior authorization requests to determine medical necessity and appropriate level of care Provide recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care Perform medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines and criteria Work with healthcare providers and authorization team to ensure timely review of services and requests Coordinate with healthcare providers and interdepartmental teams to assess medical necessity of care Escalate prior authorization requests to Medical Directors as appropriate Assist with service authorization requests for member transfer or discharge plans Collect, document, and maintain member clinical information in health management systems Provide education to providers and interdepartmental teams on utilization processes Provide feedback on opportunities to improve the authorization review process Perform other duties as assigned Comply with all policies and standards Requirements: Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing 2–4 years of related experience LPN - Licensed Practical Nurse - State Licensure required 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 Ability to work Monday–Friday, 8am–5pm Applicants must work remotely from their home anywhere within the state of Missouri Benefits: Competitive pay Health insurance 401K Stock purchase plans Tuition reimbursement Paid time off plus holidays Flexible approach to work with remote, hybrid, field or office work schedules
