Authorization Management Clinical Reviewer

Key Responsibilities

• Review acute and post-acute authorizations for medical necessity using InterQual guidelines.
• Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care.
• Participate in team meetings, educational activities, and interrater reliability testing to maintain review consistency and professional growth.
• Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes.
• Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively.

Required Qualifications

• Bachelor's Degree or equivalent work experience.
• Active RN License.
• At least 4-6 years relevant work experience.
• 2 years clinical acute nursing experience.
• 1-2 years' of hospital-based utilization management experience.

Preferred Qualifications

• Bachelor's Degree in Nursing.
• Denials and Appeals experience.
• Experience with managed care and CMS standards.
• UM/CM Knowledge of ICD / CPT / DRG’s.
• Proficient in the use of window-based computer programs.
• Excellent verbal, written, and interpersonal communication skills.
• Critical thinking skills, creative problem solving, and proficient organization and planning skills.
• Experience with InterQual guidelines for acute-care and/or other clinical decision support tools, especially in utilization management and prior authorization processes.
• Experience with CarePort Care Management.

Job Expectations

• Willing to travel up to 30% based on business needs.
• Willing to work additional or irregular hours as needed.
• Must work in accordance with applicable security policies and procedures to safeguard company and client information.
• Must be able to sit and view a computer screen for extended periods of time.

Benefits

• Excellent medical with Rx, dental, and vision benefits.
• Mental Health support through EAP.
• Generous paid time off, plus 13 paid holidays.
• 100% vested 401(K) retirement plans.
• Educational assistance up to $2500 per year.