Senior Clinical Review Nurse - Prior Authorization

Review challenging prior authorization requests to determine medical necessity and appropriate care levels per national standards and benefit coverage. Assess complex authorizations, provide recommendations to medical teams, and escalate requests to Medical Directors as needed. Manage service authorization requests for member transfers and discharge plans while ensuring timely care transitions. Collaborate with healthcare providers, utilization management, and care management teams to assess medical necessity and promote cost-effective care. Provide feedback on process improvements, educate providers on utilization processes, and train other team members on the prior authorization workflow.