Prior Authorization Nurse

STAR Medical Auditing Services is a boutique consulting firm that provides Health Information Management (HIM) and Clinical services to various organizations in the healthcare ecosystem across the U.S. We pride ourselves on providing high-quality services that are tailored to our clients’ specific needs, while creating joyful experiences along the way by treating everyone with respect and care.

STAR is currently looking for a Prior Authorization Reviewer for a remote, full-time position.

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Must be authorized to work lawfully in the United States and be domiciled within the state of California. Must also hold a current, unencumbered California Registered Nursing license.

Job Description

As a Prior Authorization Nurse, you will provide timely review of authorization requests and ensure the requests meet national standards and contractual requirements. The Prior Authorization Reviewer will also promote the quality and cost effectiveness of patient care using clinical acumen. Additionally, the nurses will prepare documentation, perform audits of patient records, and assist management as needed.

What you’ll do:

· Perform clinical reviews of authorization requests using appropriate criteria (MediCal, MCG, etc.).

· Provide accurate and complete documentation with rationale used to determine claim validity.

· Collaborate with various staff within provider networks and case management team coordinate patient care

· Ability to multitask between computer and multi-line phone requests.

· Participate in interdepartmental projects when needed.

· Enter and maintain clinical information in multiple health management systems.

· Screen medical information provided and authorization requests for medical necessity and appropriateness, compare the information to current criteria, and documentation.

· Support all UM Teams with benefit interpretation and understanding of UM policies and procedures.

· Attend staff meetings and education training necessary to maintain current nursing and UM knowledge.

· Assist with peer review audits, focused referral, and denial audits.

· Collect relevant medical information (via telephone and fax) and apply the appropriate evidence-based guidelines and medical policy.

Experience:

  • California resident
  • Two (2) or more years of utilization management experience in a health care delivery setting specifically in prior authorization.
  • Two (2) or more years of clinical experience in an acute care facility (preferred).
  • Extensive knowledge of MCG, Medicare, MediCal, Health plan guidelines required.
  • Minimum of two (2) years of experience in acute clinical nursing setting
  • Knowledge of utilization management and case management principles preferred
  • Prior authorization experience required.
  • Advanced verbal, written communication, and organization skills
  • Knowledge of Microsoft word
  • Drive to work well with a team

What you’ll bring:

License/Certification:

  • Bachelor’s or Associate Degree in Nursing (Bachelor’s preferred)
  • Active, unrestricted, and unencumbered California State licensure as a Registered Nurse (RN) required
  • Strong service orientation and professionalism

What you’ll have:

  • Deep understanding of clinical criteria for common diagnoses.
  • Attention to detail with high tolerance for extensive reading.
  • Excellent written and oral communication skills.
  • Lifelong learner who enjoys new challenges.
  • Handles change easily but also thrives in rules driven environment.
  • Reside in the state of California, and be legally able to work within the U.S.

TECHNOLOGY REQUIREMENTS

  • Reliable high-speed internet connection.
  • 50 mpbs minimum recommendation/requirement

Benefits:

· Medical, Vision, and Dental benefits

· Paid Holidays

· Paid Time Off

· Education Reimbursement

· Bereavement Leave

· Parental Leave

· HSA / FSA

· 401(k)

· Short-Term Disability

· Basic AD&D Insurance

· Basic Life Insurance - $10,000

· Fringe Benefits (Flexibility, Remote, life-Work Harmony)

Salary: $55.00 per hour

Schedule: Variable. Generally, 8-hour shifts

P.S.

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We understand that your career search may look different than others. Our hiring team wants to make sure that this would be a fit not just for us, but for you too. If you are actively looking or starting to explore new opportunities, send us your application!

STAR is dedicated to providing a safe and inclusive working environment for all. As part of our culture, we are proud to be an Equal Opportunity Employer and value our culturally diverse workforce. All qualified applicants will receive consideration for employment regardless of the person’s age, race, color, religion, sex, gender, sexual orientation, gender identity, national origin, veteran or disability status, criminal history, or any other legally protected characteristic.

California Residents: Please Click here for the California Consumer Privacy Act (CCPA) notice regarding the personal information Credit Acceptance may collect from you.

Thank You!

We know your time is valuable, and we want to sincerely thank you for applying for this position!

--STAR Medical Auditing Services’ Talent Acquisition Team

Job Type: Full-time

Pay: $35.00 - $45.00 per hour

Expected hours: 40 per week

Benefits:

  • 401(k)
  • Dental insurance
  • Flexible schedule
  • Flexible spending account
  • Health insurance
  • Health savings account
  • Life insurance
  • Paid time off
  • Parental leave
  • Professional development assistance
  • Referral program
  • Retirement plan
  • Vision insurance

Application Question(s):

  • Do you have an active, unrestricted, and unencumbered California State licensure as a Registered Nurse?
  • Are you authorized to work lawfully in the United States and reside within the state of California?
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