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