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Prior Authorization Nurse

Tempe, AZ · Healthcare
Prior Authorizations Nurse (RN or LPN) - Managed Care
Tempe, AZ (East valley suburb of Phoenix)
 
 
 *** This is a Full Time, Benefits Available, CONTRACT opportunity expected to last 6 months, or longer! ***
 
Prior Authorization Nurse Job Summary:
 
  • 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. 
  • Ensure 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.  
  • Evaluate 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 Licensed Practical Nurse (L.P.N.) license.
  • CPUR/CPUM/CPHM 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, 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.
  • 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.


#CLINICAL
 
ALENA MARTIN
SEARCH CONSULTANT

CareNational
alena@carenational.com
480.478.1635 (CALL – TEXT – FAX)
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