Prior Authorizations RN

Location: Chandler, AZ
Date Posted: 04-23-2018
CareNational
Prior Authorizations RN - Managed Care
Chandler, AZ (Greater Phoenix Area - East Valley)
 
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:
 
EXCELLENT BENEFITS AND HIGHLY COMPETITIVE SALARY OFFERED!
This growing organization is committed to the health and happiness of all their staff. They offer a comprehensive benefits package to all full-time, permanent employees including FREE Health Insurance for the Employee, as well as dental, vision, life, long term disability, flexible spending accounts, 401(k), generous PTO, paid holidays (including your birthday), and much more!

Your Background:
 
Valid, unrestricted state Registered Nurse (R.N.) license.
Around  2-3 years’ acute care clinical nursing experience.  
At least 1-3 years’ conducting Prior-Authorization/Pre-Certification or Utilization Management/Review with a Managed Care Organization (Health Plan, IPA/HMO/TPA, etc).
Knowledge of NCQA, CMS, DHS, etc and health plan requirements related to utilization management.
Intermediate computer literacy (MS Office) and strong typing skills (40 wpm) are necessary.
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. 


#CLINICAL
--
KEVIN SLAFKOSKY
DIVISION VICE PRESIDENT
CareNational
kevin@carenational.com
410.885.4745 (CALL – TEXT – FAX)

Get Informed with CareNational.tv
Managed Care News and more!
CareNational.com
Sign-Up for Job Alerts
or
this job portal is powered by CATS