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The purpose of the Prior Authorization Nurse is to provide enrollees, physicians and facilities with strong clinical support related to the review and approval of medical service authorization requests. The position supports Clever Care Health Plan goals to ensure the appropriate utilization of the organizations’ resources. This position will identify, screen, coordinate and process authorization requests covering the entire spectrum of medical services. The Nurse will use best clinical judgment to make determinations of coverage and medical necessity for requested services. This position supports Clever Care Medical Directors with case review prep including medical review criteria for PA determinations that require M.D. intervention. The PA Nurse interacts with other UM team members to support departmental efforts and goals.

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