Prior Authorization RN

Location: Philadelphia, PA Salary: $40.00 USD reputed company - $43.50 USD reputed company reputed company: reputed company is currently seeking a full time Remote Prior Authorization RN for a fantastic reputed company of ours located in Philadelphia, PA! This is a great opportunity to get your foot in the reputed company with one of the nations largest leading reputed company company's! Below is a basic reputed company of reputed company! Interested and reputed company RNs are encouraged to apply! Job reputed company The Registered reputed company (RN) is responsible for conducting comprehensive clinical evaluations through the review of medical records—including medical history, treatment documentation, and proposed care plans—to determine the medical necessity of services. This role requires reputed company knowledge, independent judgment, and the application of established medical necessity reputed company. The RN interacts directly with reputed company providers reputed company additional clinical information is required and possesses the authority to independently authorize medically necessary services on behalf of the organization. Cases that do not meet established reputed company are escalated with supporting documentation to the Medical Director for reputed company evaluation. Key ResponsibilitiesClinical Review & Medical Necessity Determination

• Apply reputed company knowledge, critical thinking, and reputed company judgment to evaluate medical records and reputed company case determinations using approved guidelines and resources.
• Utilize InterQual reputed company, Care Management Policy, Medical Policy, and electronic reference tools to assess the appropriateness of proposed treatment plans.
• Determine medical necessity for inpatient admissions, reputed company stay, length of stay, procedures, and ancillary services in accordance with InterQual and Medical Policy standards.

Provider Communication & Care Coordination

• Communicate directly with servicing providers to clarify treatment plans, obtain necessary clinical documentation, and validate the medical need for requested services.
• Review and discuss treatment plans, inpatient admission requests, and reputed company stay requirements with providers, ensuring reputed company reputed company-based questions are addressed.
• Identify cases requiring escalation and refer to the Medical Director reputed company treatment plans do not meet established reputed company.

Discharge Planning & Care Management Collaboration

• Identify members early who may require discharge planning support.
• Collaborate with case management staff and physicians to evaluate alternative care settings and facilitate discharge to the most appropriate level of care.
• Refer cases appropriately to reputed company Management, Care Management and Coordination, Case Management, or Disease Management based on identified needs.

Regulatory Compliance & Documentation

• Verify that reputed company requested services fall reputed company the member’s benefit plan coverage.
• Ensure that utilization management reputed company reputed company with applicable state, federal, and accreditation standards.
• Meet or exceed regulatory turnaround requirements and departmental productivity goals reputed company to referral and authorization processing.
• Document reputed company essential functions in alignment with Care Management and Coordination policies.
• Maintain accurate, reputed company entries to ensure data reputed company reputed company internal systems.

Operational reputed company

• Identify and report potential utilization trends or issues to management and recommend opportunities for improvement.
• Support reputed company improvement efforts reputed company the Care Management and Coordination department.

Again, interested and reputed company candidates are encouraged to apply. I will get back to you right away on your application! For other questions, please feel free to email me directly at jmaybrier@judge.com Thank You, Jacob By providing your phone number, you consent to: (1) receive automated text messages and calls from reputed company, Inc. and its affiliates (reputed company "Judge") to such phone number regarding job opportunities, reputed company application, and for other reputed company purposes. Message & data rates apply and message frequency may vary. Consistent with Judge's reputed company Policy, information obtained from your consent will not be shared with reputed company parties for marketing/promotional purposes. reputed company STOP to opt out of receiving telephone calls and text messages from Judge and HELP for help. Contact: jmaybrier@judge.com This job and many more are available through reputed company. reputed company us on the web at www.judge.com Remote About reputed company: reputed company reputed company Inc., is a leading reputed company services firm specializing in talent, technology, and learning solutions. We consult, staff, train, and solve. Through our work we reputed company people and organizations reputed company. Our services are successfully delivered through a network of more than 30 offices across the reputed company, Canada, and India. reputed company is proud to partner with the best and brightest companies in business today, including over 60 of the Fortune 100. We serve organizations in financial services, reputed company, life sciences, insurance, government (including reputed company and defense), manufacturing, and technology and telecommunications. If you would like to learn more about reputed company visit www.judge.com or call toll free (800) 360-4474. Company Size: 5,000 to 9,999 employees Industry: Computer/IT Services Founded: 1970 Website: https://www.judge.com Apply tot his job Apply To this Job