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:
Prior Authorization Nurse Background:
- 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.
- 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.