Job Details
Job Title: Prior Authorizations Registered Nurse (RN)
Summary:
The UM Prior Authorization Nurse is responsible for evaluating referrals for medical services to determine medical necessity and appropriate course of action. Utilizing independent judgment, extensive medical knowledge, and adherence to clinical guidelines, the Prior Authorization Nurse collaborates with the Nursing Manager, VP of Clinical Policy, and/or Medical Director as needed for utilization management and issue resolution.
Essential Duties:
- Review prior authorization referrals for medical necessity, exercising independent judgment and medical expertise.
- Independently assess provided records to determine patient's eligibility for requested services.
- Ensure compliance with health plan, state, and clinical guidelines in decision-making process.
- Develop clinical summaries justifying approval or denial of requested services.
- Make independent decisions to approve or deny services based on assessment.
- Provide recommendations for Medical Director review in cases of denial based on insufficient information.
Qualifications/Experience:
- Bachelor s or Associate Degree in Nursing (Bachelor s preferred).
- Current CA State licensure as Registered Nurse (RN) or Licensed Vocational Nurse (LVN).
- Minimum 2 years of experience in a comparable position.
- Prior authorization or Managed Care experience preferred.
Skills:
- Ownership/Dependability: Demonstrates accountability for assigned tasks, adheres to work schedules, practices effective time management, and accepts responsibility for errors.
- Attendance: Maintains excellent attendance and dependability due to the critical nature of the role.
- Attention to Detail: Possesses keen attention to detail when reviewing medical records and clinical guidelines.
Overview/Day-to-Day:
- Receive nurse assignments by 8:30 AM daily, with a minimum daily requirement.
- Process approximately 55-65 new cases per day, sharing work queue with 1-2 other nurses.
- Address deferred cases from the previous day and review any new submissions.
- Handle cases across all health plans and lines of business, requiring sharp attention to detail.
Top Requirements:
- Managed Care Experience with another MSO or Health Plan.
- Minimum of 2 years Prior Authorization experience.
- Minimum of 2 years clinical/nursing experience.