We have partnered with a large valley managed care employer with a major initiative and need to ramp up their clinical staff! Temp to hire positions! Clinical Reviewer – LPN – up to $25 an hour. Tempe and North West Phoenix locations.
Need at least 2 years of medical/surgical experience and preferably utilization management experience.
Please send resume directly to: firstname.lastname@example.org
Applies clinical knowledge to make determinations for pre-authorizations of specific procedures and services to ensure adherence to contract benefits. Conducts Medical / Surgical medical necessity reviews. Compiles information needed to process prior authorization requests and documents in the medical management information system. Prepares and presents more complex cases for Medical Director review. Refer cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.
Education & Experience Required
Licensed Practical Nurse or Licensed Vocational Nurse, with current unrestricted license in Arizona.
2+ years experience with Medical / Surgical
Proficient working with on-line systems
Managed Care experience
Conducts prior authorization activities and referral management activities.
Assesses medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines, Clinical Decision Support Tool, and Behavioral Health criteria. Interprets information and makes decision whether authorizations fits the benefit program. Ensures timely reviews for requesting facilities and appropriate notification to parties. Contacts beneficiary and / or provider to obtain or clarify medical information as necessary. Refers cases to Case Management, Care Coordination, or Disease Management for review as necessary. Prepares cases for Medical Director and Peer Review according to established policy. Refers potential quality issues and complaints to Clinical Quality Management. Notifies Internal Audit & Corporate Compliance department of cases for review of potential fraud.
Performs other duties as assigned.
Regular and reliable attendance is required.
Knowledge of Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, working knowledge of medical coding
Team-Building / Team Player
Influence the actions and opinions of others in a positive direction and build group commitment.
Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-oriented