[Hiring] Authorization Nurse, RN @PriMed Management Consulting Services, Inc.

Role Description

The Utilization Management team facilitates the review of requests for medical necessity to assure that care is provided to our members timely, at the correct level of care with quality and cost effectiveness standards. The Utilization Management Nurse will report to the Supervisor of Utilization Management.

In this role, the Authorization Nurse will evaluate authorization requests and authorize, modify, dismiss, or pend per appropriate criteria. This role is a fast production-based environment with a need for teamwork.

Job Responsibilities

• Review and process urgent and non-urgent authorization requests (via phone, fax, and electronic submission) for medical necessity according to established criteria.
• Review for medical necessity, coding accuracy, medical policy compliance, benefit eligibility and contract compliance.
• Finalize authorization status as appropriate (approve, deny, dismiss, close).
• Provides referrals to Case management and Quality Departments as needed.
• Support team through consistent and successful caseload management to achieve team goals, regulatory timelines, and accreditation standards.
• Triages and prioritizes cases and other assigned duties to meet required turnaround times.
• Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements.
• Obtain additional relevant medical information as necessary from requesting provider.
• Communicate with providers and members regarding status of authorization requests.
• Collaborate with Medical Directors and other designated physician leaders for making clinical decisions.
• Refer authorization requests not meeting criteria to specialty teams according to established medical necessity, benefit, and eligibility criteria to assure appropriate, efficient, and timely medical care.

Qualifications

• Current active, unrestricted California Licensure: Registered Nurse (RN).
• Minimum three years hands-on clinical nursing experience.
• Excellent verbal and written communication skills.
• Ability to work effectively with a variety of stakeholders including physicians, office staff, and members.
• Ability to work independently with self-initiative and discipline.
• Ability to be a part of a team to meet the goals of the Prior Auth department.
• Effective written and oral communication skills.
• Working familiarity of ICD-10 diagnostic codes, CPT coding, HCPC coding.
• Working knowledge of personal computers.
• Optimum organizational skills with ability to meet expected and unexpected time frames.

Preferred

• Payor side Utilization Management Prior Auth experience preferred.
• Delegated model experience preferred.
• Working familiarity with UM regulations: DMHC, NCQA, CMS, Medi-Cal.

Required Education

• Graduate of an Accredited RN program.

Required Licensure

• Active unrestricted RN in the State of California.

Additional Information

• Salary: $100,000 - $120,000 Annual.