Prior Authorization Coordination RN

BJC HealthCare • St. Louis, MO

10d • Onsite

About The Position

St. Louis Children’s Hospital is dedicated to improving the health and lives of children. As one of the top-ranked children’s hospitals in the country, St. Louis Children’s provides care in more than 50 specialty areas through a dedicated team of physicians, nurses, staff and volunteers. Along with inpatient and outpatient medical care, the hospital offers education, wellness and injury-prevention programs to fulfill its mission to “do what’s right for kids.”
Providing comprehensive, high-quality care and serving as an advocate for children has been St. Louis Children’s commitment since its inception in 1879. Today, the hospital serves patients and families across a 300-mile service area, and has seen patients from all 50 states and more than 80 countries.
St. Louis Children’s consistently ranks among America’s Best Children’s Hospitals by U.S.News & World Report in all surveyed categories. In 2021, St. Louis Children’s was one of eight children’s hospitals to rank in the top 25 of all 10 specialties. The hospital’s academic and physician partner, Washington University School of Medicine, is one of the top-ranked medical schools in the United States. Since 2005, St. Louis Children’s has been designated as a Magnet® hospital for nursing excellence from the American Nurses Credentialing Center® (ANCC).
Role Purpose
Ensure that the administration of hospital resources are appropriate, efficient and fall within the parameters of the patient's payment structure while providing safe and quality care. Evaluate the cost and quality of medical services provided by the medical team. Ensure appropriate utilization, which includes the evaluation of potential under and over-utilization according to patient's presentation and documentation. Education of medical providers and other health care professionals on the appropriate and cost-effective use of health care resources.

Requirements

• Nursing Diploma/Associate's - Nursing
• 2-5 years
• RN

Nice To Haves

• 2 years of RN experience
• 1 year of Utilization Review/Utilization Management experience
• Prior hospital-based/provider office authorization experience
• Bachelor's Degree - Nursing

Responsibilities

• Engage with various clinics to ensure proper level of care is pre-certified prior to admission.
• Run and review reports for out of network or out of state Medicaid plans and escalate to appropriate team members to initiate contracting.
• Collaborate with transplant and surgical service lines for upcoming admissions and high dollar inpatient stays.
• Uses clinical and analytical skills to review and interpret diagnostic test results to determine appropriateness of patient's level of care.
• Uses Interqual Criteria to determine level of care for all elective inpatient hospitalizations to assure services are provided in the appropriate setting.

Benefits

• Comprehensive medical, dental, vison, life insurance, and legal services available first day of the month after hire date
• Disability insurance paid for by BJC
• Annual 4% BJC Automatic Retirement Contribution
• 401(k) plan with BJC match
• Tuition Assistance available on first day
• BJC Institute for Learning and Development
• Health Care and Dependent Care Flexible Spending Accounts
• Paid Time Off benefit combines vacation, sick days, holidays and personal time
• Adoption assistance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree