[Hiring] Prior Authorization/Concurrent Review Nurse @Central Health

Role Description

This role involves working with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review, and other utilization management activities aimed at providing members with the right care at the right place at the right time.

• Provides daily review and evaluation of members that require hospitalization and/or procedures, providing prior authorizations and/or concurrent review.
• Mentors and trains new team members.
• Assesses services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.
• Utilizes clinical skills to review and monitor members' utilization of health care services.
• Performs telephonic reviews of inpatient hospital admissions and assists with the coordination of discharge planning needs.
• Obtains necessary information to assess a member's clinical condition and identify ongoing clinical care needs.
• Evaluates options and services required to meet the member's health needs in support and collaboration with disease management interventions.
• Performs prospective, concurrent, and retrospective review of inpatient, outpatient, ambulatory, and ancillary services requiring clinical review.

Hours of operation are Monday through Friday 8 am to 5 pm, including extended hours that may occur on weekends and/or holidays as required by State and Federal regulations.

This position is considered Remote, with occasional visits required to a Central Health office in Austin, Texas. Remote work is not available for residents of California, Colorado, New York, New Jersey, Hawaii, Maryland, Montana, Pennsylvania, Virginia, or Washington.

Qualifications

• High School Diploma or equivalent Required
• Completion of an accredited (RN) or an accredited (LVN) program Required
• One (1) year clinical practice experience Required
• Two (2) years managed care experience with utilization management and/or case management

Requirements

• Active, unrestricted State Registered Nursing license in good standing

Company Description