Prior Authorization Nurse (RN) - Managed Care
Chandler, AZ (Phoenix Area - East Valley)
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.
Prior Authorization Nurse Benefits:
- 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.
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!