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Prior Authorization Nurse (Texas Residents Only)

2-4 years
$46 per hour
10 Aug. 2, 2024
Job Description
Job Type: Full Time Remote Education: B.Sc./ M.Sc./ M.Pharm/ B.Pharm/ Life Sciences Skills: Causality Assessment, Clinical SAS Programming, Communication Skills, GCP guidelines, ICD-10 CM Codes, CPT-Codes, HCPCS Codes, ICD-10 CM, CPT, HCPCS Coding, ICH guidelines, ICSR Case Processing, Interpersonal Skill, Labelling Assessment, MedDRA Coding, Medical Billing, Medical Coding, Medical Terminology, Narrative Writing, Research & Development, Technical Skill, Triage of ICSRs, WHO DD Coding

Position Purpose:

The role involves analyzing prior authorization requests to determine the medical necessity of services and appropriate levels of care. This assessment is conducted in accordance with national standards, contractual requirements, and the member’s benefit coverage. The position requires providing recommendations to the medical team to ensure quality and cost-effective medical care.

Education/Experience:

  • Graduate from an accredited School of Nursing or Bachelor’s degree in Nursing.
  • 2–4 years of related experience.
  • Preferred: Clinical knowledge with the ability to analyze authorization requests and determine medical necessity.
  • Preferred: Knowledge of Medicare and Medicaid regulations and utilization management processes.

Day-to-Day Responsibilities:

  • Conduct medical necessity and level of care reviews for requested services using clinical judgment.
  • Refer cases to Medical Directors for further review when necessary.

Performance Expectations/Metrics:

  • After training, process 15-17 authorizations per day.

First Day Overview:

  • Set up all necessary systems and meet with a preceptor.
  • Participate in a 4-week learning journey, followed by training with a preceptor on the team.

Previous Job Titles or Background:

  • RN or LVN nursing experience is beneficial.

About MRI:

Media Riders Inc. (MRI) is a family-owned recruitment and staffing services company. We provide recruitment and payroll services to clients supporting State and Federal funded programs. As an SBA-certified Women-Owned Small Business (WOSB) and Texas certified Historically Underutilized Business (TxHub), we are committed to serving our clients with excellence.