Prior Authorization Nurse - Health Plan

Location: Tucson, AZ
Date Posted: 08-01-2018
Prior Authorizations Nurse (RN or LPN) - Managed Care
Tucson, AZ
Your Job Summary:
The role of the Prior Authorization Nurse is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization specialty referral requests.  Under the direction of the Prior Authorizations Supervisor, the Prior Authorizations Nurse ensures that prior authorization requests are completed in a timely fashion to meet contractual requirements and that all reviews are conducted using nationally recognized and evidence based standards.  Evaluates the pre-service authorization request received for scheduled inpatient admissions, ambulatory surgeries, outpatient services, and out of network providers.  As needed, they will forward requests to the appropriate physician or medical director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed.
Your Reward:
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health.
Your Background:
Current, valid, and unrestricted state Licensed Practical Nurse (L.P.N.) or Registered Nurse (R.N.) license.
CCM or CPUR/CPUM or similar certification is preferred.
Roughly 2-4 years acute care clinical nursing experience is required.
Around 3-4 years of recent experience in Prior Authorization, Pre-Certifications, or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
Your Duties:
The Prior Authorizations nurse provides oversight for authorizing those services that require prior authorization, acts as a liaison with the established provider network.  Utilizes designated criteria along with clinical knowledge to make authorization decisions and assist with review determinations.  Evaluates all requests for service, to determine the Company's financial liability including the collection of information regarding subrogation and COB and entry in the automated system.  Responsible for implementing and coordinating all utilization management functions relating to the pre-authorization of select outpatient testing, surgery, and elective inpatient admissions.  Initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information.  Ensures accurate coding using CPT-4 and ICD-9 codes and documents all information accurately.   Applies appropriate benefits information to determine if requested services are a covered benefit.  Applies medical knowledge and experience to authorize pre-service requests.  Identifies cases appropriate for case management and makes appropriate referrals. Identifies potential quality of care issues and refers to the Quality Department.  Prepares documentation and presents prior authorization requests to the Medical Director for additional review. This position works closely with the Notice of Action (NOA) coordinator to develop and review denial letters. Meets service standards for decision turn-around times and written correspondence. 
480.264.0620 (CALL – TEXT – FAX)
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