Case Manager/Prior Authorization RN- Pain & Wound Clinics

Licking Memorial Health Systems•Newark, OH

About The Position

The case manager/prior authorization RN reviews upcoming medical treatments, services, or procedures for the pain and wound clinic's patient populations to determine whether their procedure or therapy qualifies for insurance coverage. The nurse assesses, evaluates, and provides recommendations to help ensure patients receive the services they need. Responsible for working denial queues to facilitate resolution for denied claims.

Requirements

Graduate from an accredited school of nursing and licensed in the state of Ohio.
Ability to carefully review medical records and ensure accuracy in data entry when providing information for prior authorization requests.
Excellent verbal and written communication skills
Excellent computer skills.

Nice To Haves

Previous case management, utilization review, or prior authorization experience preferred.
Familiarity with electronic health records (EHR) and prior authorization platforms helpful.

Responsibilities

Accurate review of coverage benefits and payer policy limitations to determine the appropriateness of requested services.
Works closely with pain, wound staff, and schedulers for upcoming patient procedures, rescheduled procedures, and denials.
Follows up with patients as necessary.
Performs timely prospective and retrospective reviews for services requiring prior authorization as well as timely concurrent review for continuation of care services.
Follows the authorization process using established criteria as set forth by the payer or clinical guidelines.
Works with the pain and wound providers to facilitate/participate in peer-to-peer reviews.
Manages electronic work queues and documents detail as applicable in the medical record.
Works closely with clinical staff, clinic providers, compliance, billing, and coding to ensure cases are authorized appropriately.
Facilitates the completion of medical leave and disability paperwork for patients as necessary.
Completes Bureau of Workman’s Compensation (BWC) forms for patients as necessary.
Assists patients with the appeal and denial process.
Provides clinical information (utilization review) to external providers and managed care organizations.
Participates in data collection for department dashboards.
Coordinates insurance/patient’s condition changes with providers(s)/Physician’s Assistant as applicable.