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            Conduct a Nurse Review of the Authorization Request

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            Conduct a Nurse Review of the Authorization Request

            As a nurse, you’re responsible for performing an effective clinical review of an authorization request to ensure healthcare services are compliant and are delivered with quality and cost efficiency.

            Required Editions

            Available in: Lightning Experience

            Available in: Enterprise and Unlimited Editions with Health Cloud
            User Permissions Needed
            To conduct a nurse review: Health Cloud Utilization Management, OmniStudio User, and RuleEngine Runtime permission sets

            Facilitate the authorization and coordination of requests in adherence with your defined network of providers, clinical guidelines, and your organization’s approval criteria. You can either approve the request or refer it for further review by the Medical Director. During the review, your focus is to:

            • Evaluate the accuracy of member eligibility and benefit verification, and network utilization
            • Appropriately identify criteria and refer to industry-standard medical necessity review guidelines for making the right clinical decisions
            • Prepare authorization request for next level of review
            • Ensure timely coordination with providers to gather additional documents
            • Be compliant with turnaround timeframes for authorization reviews and provider notification
            • Mark comments and observations on services requested, clinical documents, and overall assessment of the request
            1. From the App Launcher, find and select the Utilization Management for Payers app.
            2. Select the case record to review.
            3. Click Start Utilization Management Nurse Review.
            4. Verify eligibility status, authorization details, provider details, and clinical documents.
            5. In the Update Clinical Documents window, upload additional documents that you receive from the provider.
            6. In the Review Request window, indicate the status of the clinical documentation and clinical guidelines.
            7. Specify your review decision, the reason, and any notes or comments.
            8. When you’re done, click Submit.
             
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