Prior Authorization, RN, CO
R0001871
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Job Description:
The Prior Authorization, Nurse is responsible for clinical review of requests for health care services.
Essential Functions:
ā¢ Assesses appropriateness of service requests based on established Medicare and Health Plan standards and guidelines
ā¢ Evaluates the requested care needs of the PHP member using clinical judgement and critical thinking skills
ā¢ Supports physicians and providers in maintaining a focus on quality care enforcement for the Physician Health Partners members
ā¢ Participates in identifying issues related to the prior authorization process and seeks creative solutions to resolve issues
ā¢ Collaborates with team members to ensure incoming service requests are managed within allotted processing time and Medicare required turn-around time
ā¢ Identifies potential need for interdisciplinary collaboration and facilitates referrals as needed
ā¢ Documents service request review activity in a clear, concise, and accurate manner consistent with the internal review processing rules
ā¢ Maintains confidentiality and ensures compliance with HIPAA regulations
ā¢ Other duties as assigned
Knowledge, Skills and Abilities:
ā¢ Strong clinical knowledge and critical thinking skills
ā¢ Knowledge of Prior Auth process, NCQA guidelines, CMS - Medicare regulations, HMO Product structure rules and referral requirements
ā¢ Excellent verbal and written communication skills
ā¢ Great customer relation skills
ā¢ Team focused with strong collaborative skills
ā¢ Independent problem-solving skills
ā¢ Self-motivated and self-managed
ā¢ Proficient in Microsoft Office Suite
Qualifications:
ā¢ RN with valid license in good standing
ā¢ 3-5 years clinical nursing experience required
ā¢ Previous utilization management, case management or discharge planning experience preferred
ā¢ Experience with Microsoft Excel and Microsoft Teams (preferred)
ā¢ Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures.
Salary Range:
$63,502.40 -$90,719.20
Apply tot his job
Apply To this Job
Are you looking to work for a company that has been recognized for over a decade as a Top Place to Work? Apply today to become a part of a company that continues to commit to putting our employees first.
Job Description:
The Prior Authorization, Nurse is responsible for clinical review of requests for health care services.
Essential Functions:
ā¢ Assesses appropriateness of service requests based on established Medicare and Health Plan standards and guidelines
ā¢ Evaluates the requested care needs of the PHP member using clinical judgement and critical thinking skills
ā¢ Supports physicians and providers in maintaining a focus on quality care enforcement for the Physician Health Partners members
ā¢ Participates in identifying issues related to the prior authorization process and seeks creative solutions to resolve issues
ā¢ Collaborates with team members to ensure incoming service requests are managed within allotted processing time and Medicare required turn-around time
ā¢ Identifies potential need for interdisciplinary collaboration and facilitates referrals as needed
ā¢ Documents service request review activity in a clear, concise, and accurate manner consistent with the internal review processing rules
ā¢ Maintains confidentiality and ensures compliance with HIPAA regulations
ā¢ Other duties as assigned
Knowledge, Skills and Abilities:
ā¢ Strong clinical knowledge and critical thinking skills
ā¢ Knowledge of Prior Auth process, NCQA guidelines, CMS - Medicare regulations, HMO Product structure rules and referral requirements
ā¢ Excellent verbal and written communication skills
ā¢ Great customer relation skills
ā¢ Team focused with strong collaborative skills
ā¢ Independent problem-solving skills
ā¢ Self-motivated and self-managed
ā¢ Proficient in Microsoft Office Suite
Qualifications:
ā¢ RN with valid license in good standing
ā¢ 3-5 years clinical nursing experience required
ā¢ Previous utilization management, case management or discharge planning experience preferred
ā¢ Experience with Microsoft Excel and Microsoft Teams (preferred)
ā¢ Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures.
Salary Range:
$63,502.40 -$90,719.20
Apply tot his job
Apply To this Job