Job Description
R0001871
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:
- Assesses appropriateness of service requests based on established Medicare and Health Plan standards and guidelines
- Evaluates the requested care needs of the PHP member using clinical judgement and critical thinking skills
- Supports physicians and providers in maintaining a focus on quality care enforcement for the Physician Health Partners members
- Participates in identifying issues related to the prior authorization process and seeks creative solutions to resolve issues
- Collaborates with team members to ensure incoming service requests are managed within allotted processing time and Medicare required turn-around time
- Identifies potential need for interdisciplinary collaboration and facilitates referrals as needed
- Documents service request review activity in a clear, concise, and accurate manner consistent with the internal review processing rules
- Maintains confidentiality and ensures compliance with HIPAA regulations
- Other duties as assigned
- Knowledge, Skills and Abilities:
- Strong clinical knowledge and critical thinking skills
- Knowledge of Prior Auth process, NCQA guidelines, CMS - Medicare regulations, HMO Product structure rules and referral requirements
- Excellent verbal and written communication skills
- Great customer relation skills
- Team focused with strong collaborative skills
- Independent problem-solving skills
- Self-motivated and self-managed
- Proficient in Microsoft Office Suite
- Qualifications:
- RN with valid license in good standing
- 3-5 years clinical nursing experience required
- Previous utilization management, case management or discharge planning experience preferred
- Experience with Microsoft Excel and Microsoft Teams (preferred)
- 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