Job ID: JP00045714
Anticipated Start Date: 07/28/2025
Please note this is the target date and is subject to change. Mindlance will send official notice ahead of a confirmed start date.
Responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines.
Primary duties may include, but are not limited to:
- Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
- Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.
- Notifies ordering physician or rendering service provider office of the preauthorization determination decision.
- Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits.
- Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. Partners with more senior colleagues to complete non-routine reviews.
- Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.
- Follows-up to obtain additional clinical information.
- Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.
Requirement
- Requires AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background.
- Current unrestricted RN license in applicable state(s) required.
- Bilingual required.
Preferred
- Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.
- BA/BS degree preferred. Previous utilization and/or quality management and/or call center experience preferred.
Job Type
- Contract Opportunity
Additional Details
- Nurse can be LPN or RN.
- Excellent computer skills are critical.
- The ideal candidate will have prior authorization nurse experience at a health plan and have worked with Medicare and Medicare criteria.
- We are a Medicare Advantage plan and handle pre-service outpatient and elective inpatient authorization requests for a variety of services and items sent in from PCPs, other providers and members. May be required to do outreach to PCP/members, if needed.
- Hours are 8am-5pm M-F or Tuesday-Saturday. This schedule may be different dependent on needs and one weekend on month (on rotation) also depending on needs.
- Candidates need to be within 50 miles of a FL Pulsepoint, but the position is remote.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
About Mindlance:
Founded in 1999, Mindlance is a certified diversity business and has been on the Staffing Industry Analysts list of Fastest-Growing US Staffing Firms twelve times. As a top-performing partner to leading workforce programs, Mindlance is known for delivering consistently high-quality tech first talent solutions. Our strong processes help clients build agile and diverse workforces, while creating an ease of onboarding and service to our consultants.
Mindlance provides specialized staffing solutions across the Healthcare industry and associated skill domains. Headquartered in Union, NJ with presence in over 40 key locations across US, Canada and India, servicing 200+ global clients and 5000+ consultants. Our services include Direct Sourcing, Global EoR & AoR, Payroll, Returnship, and Recruit-Train-Deploy solutions. With over $400 million in annual revenue, our success is rooted in a mindful commitment to balance in work, from which our name is derived.
Mindlance is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.
To learn more about how Mindlance collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. Mindlance will only use this information to complete the recruitment process.
This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.