Prior Authorization Nurse (RN or LVN) – Managed Care
*** This is a Full Time, Benefits Available, CONTRACT opportunity expected to last 3-4 months, or longer! ***
Prior Authorization Nurse Job Summary:
Prior Authorization Nurse Background:
- 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.
- Current, valid, and unrestricted state Registered Nurse (R.N.) or Licensed Vocational Nurse (L.V.N.) license.
- CCM or CPUR or similar certification is preferred
- 2-4 years acute care clinical nursing experience is required.
- Around 2-3 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).
- 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.