LVN or RN -Prior Authorization Nurse
Under the general direction of the Director, the Prior Authorization Nurse conducts prospective review of authorization requests including selected specialties, medical treatments and services, elective hospital admissions, ancillary services, home care and out of network referrals. The nurse makes clinical decisions based on established criteria and regulatory requirements. Prepares documentation and presents prior authorization requests to the Medical Director for additional review. Manages the utilization of membership, conducts chart review for medical appropriateness of services, and ensures that quality care is delivered in a cost-effective, timely manner. The Prior Authorization Nurse works in coordination with an interdisciplinary team to achieve the organization mission as well as department specific goals and objectives.
- Degree in Nursing from an accredited college.
- Current unrestricted Licensed Vocational Nurse (LVN) or Registered Nurse (RN) license for the State of California- required.
- Knowledge of HMO/IPA requirements and benefits that apply to the utilization management process- preferred.
- At least three (3) years of prior clinical experience: hospital clinical/direct patient care experience required
- At least (2) years of prior managed care experience: acute hospital case management, discharge planning, complex case management or utilization management- preferred.
- At least one (1) year experience applying medical criteria and guidelines (MCG and/or InterQual) is strongly preferred.
- Excellent computer skills.
- Ability to use multiple electronic systems, software programs, and the internet to review and record information.
ESSENTIAL DUTIES ANDRESPONSIBILITIES
- Ensures authorizations are processed according to established timelines, benefit coverage, and medical necessity criteria within the appropriate provider network.
- Perform prior authorization process by clinical review of requests requiring medical review and entering authorizations into the system.
- Provides clear and accurate documentation on rational for approving request or reason
- for sending to the Medical Director for additional review.
- Accurately and consistently apply appropriate clinical review guidelines to authorization requests.
- Monitors that all services are being delivered in the most the appropriate setting and level of care and appropriate providers are involved with all aspects of care required..
- Identifies services required by health plan members that cannot be provided within the IPAs network of providers and locates alternative providers and facilities as needed.
- Acts as a liaison and resource in collaboration with physicians and physicians office staff, hospitalists, care facilities, ancillary providers, members, health plan case managers and internal departments.
- Ensures delay, denial and termination notification of services are delivered timely and that the member and providers are notified of appeal rights appropriately.
- Interprets data and trends using appropriate analytical skills to include utilizing existing reports and systems to identify and monitor utilization patterns.
- Provides timely responses to inquiries from health plans and providers concerning members regarding the prior authorization requests.
- Makes appropriate referrals and coordinates as needed with the health plan for delegated and non-delegated prior authorization reviews and coordination of care activities.
- Identifies members who are appropriate for case management services anwho will need oversight of inpatient case management and compliance to avoid unnecessary readmissions.
- Works closely with UM department, Quality Management, Provider Services, Contracting and Claims staff to prevent duplication of services, ensure appropriate care is rendered to contracted providers, identify high risk patients, and support quality improvement initiatives.
- Assists in data collection for special studies, and medical chart reviews to meet the organizations goals and objectives.
- Participates in department program planning including goal setting, program development, systems development and improvement.
- Other duties as requested or assigned.
EXCEL provides comprehensive health care management services with a personalized approach to meet each clients needs. EXCEL combines advanced technological solutions with a sophisticated level of healthcare expertise to provide effective management and solutions to a rapidly changing health care environment. EXCEL has been operating as an independent health care management company since 2001, although originally rooted during 1980 as an institutional management arm.