Prior Authorization RN - Health Plan

Location: Atlanta, GA
Date Posted: 02-01-2018
Prior Authorization RN - Managed Care
*** Candidates must be licensed RN in Georgia, and live in the greater Atlanta metro area ***
** This is a full-time, benefits available, CONTRACT opportunity, expected to last 3 months or longer! **
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:
Your Background
Current, valid, and unrestricted state 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 1-2 years of recent experience in Prior Authorization or Pre-Certifications 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.
Prefer 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.
Erik Berg
Search Consultant

CareNational Healthcare Services

443.470.8240 (CALL – TEXT – FAX)

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