Prior Authorization Nurse, Behavioral Health

Location: Orange, CA
Date Posted: 04-16-2018
Prior Authorization Nurse (RN or LVN) - Behavioral Health
Orange, CA
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 6 months, or longer! ***

Prior Authorization Nurse Job Summary:
  • 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. 
  • 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.
Prior Authorization Nurse Background:
  • Current, valid, and unrestricted state Registered Nurse (R.N.) or License Practical Nurse (L.P.N.) license.
  • CCM or CPUR or similar certification is preferred
  • 2 years acute care clinical nursing experience is required.
  • Behavioral Health experience (e.g. inpatient psychiatric setting, outpatient mental health services, Applied Behavior Analysis for Autism Spectrum Disorder) preferred
  • 1 year of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
  • Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
  • Maintain an understanding of current CPT-4, ICD-10 and HCPCS codes and continual updates to knowledge base regarding the codes.
  • 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.
Erik Berg
Search Consultant

CareNational Healthcare Services

443.470.8240 (CALL – TEXT – FAX)

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