Prior Authorization Nurse Navigator

The Health Plan of West Virginia Inc•Wheeling, WV

About The Position

Coordinates and integrates through review, all services that require pre-authorization including all new technology and experimental/investigational services using the clinical review algorithm and/or responsible to identify members that may require coordinated care management or disease management services, or transition of care services based on clinical risk scores, or information gathered from preauthorization review of submitted clinicals.

Requirements

Registered Nurse with at least five (5) years’ experience. Three (3) of those years may be work experience as a nurse’s aide, LPN or other appropriate position in a clinical setting. (RN outside minimum experience may be waived for internal applicants currently employed as an LPN with written recommendation of current supervisor or manager). Preferred critical care or other acute care experience.
Active Ohio or WV licensure upon hire. Ohio or West Virginia multistate licensure must be obtained within the 90-day probationary period and maintained throughout employment including compliance with State Boards of Nursing and continuing education policy. Other licensure as company expansion warrants.
Demonstration of excellent oral, written, telephonic and interpersonal skills.
Demonstration of proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems.
Flexibility and demonstration of the ability to balance an independent and team working environment, multitask, work in a fast-paced environment, and adapt to changing processes.
Possession of a superior work ethic and a commitment to excellence and accountability.
Proven ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues.

Nice To Haves

Utilization Management, Quality Improvement, Case Management, Disease Management, or other Managed Care experience is desirable.
Certification in an area of clinical expertise related to current work i.e., CDE, CCM, CMCN, Motivational Interviewing/MI Trainer, etc.

Responsibilities

Enters data timely into preauthorization system and updates diagnoses, procedures, medical histories, and consults.
Determines appropriateness of pre-authorizations using established clinical/behavioral health criteria and/or guidelines as appropriate per line of business.
Reviews and evaluates relevant information including member history, medical records, group contracts, benefit design, plan limitations, exclusions, coordination of benefits and member eligibility in making decisions and recommendations that are consistent with sound medical and managed care practice.
Appropriately forwards service requests that do not meet guidelines per clinical algorithm to the medical director.
Submits requests for Single Case Agreements and/or Letters of Agreement per process according to line of business.
Coordinates care in collaboration with the member, family, health care team members, providers, and other resources to intervene proactively to identify needed medical and/or behavioral health services.
Identifies members that may need chronic disease navigation, complex case navigation, behavioral health, social service intervention and refers appropriately.
Acts as a liaison between member, provider, and The Health Plan.
Collaborates and shares knowledge and expertise with peers, supervisors, and other staff.
Serves as assigned or as volunteers on departmental or company committees and attends departmental or work-group meetings as scheduled.
Promotes communication, both internally and externally, to enhance effectiveness of medical management services.
Identifies opportunities for improvement in systems, processes, functions, programs, procedures and makes recommendations to the appropriate management staff.
Prioritizes assignments/referrals appropriately and maintains flexibility as new priorities arise.
Identifies potential quality issues, variances, hospital acquired conditions and never events and refers to QI Department.
Identifies requests for new technology and communicates that data to the medical policy director.
Takes after-hours and weekend call on rotation as assigned (volunteer only).
Strives to improve quality in all areas of responsibility and cooperates with all departments to improve quality through The Health Plan.
Facilitates access to care, provides liaison services, advocates for, and educates members as needed.
Educates providers when indicated.
Identifies and reports potential high-cost cases to the reinsurance or stop loss carrier as appropriate per line of business.
Demonstrate a working knowledge and adherence to contractual guidelines and policies of The Health Plan.
Achieve optimal clinical and quality outcomes by effectively managing care and resources.
Participate in quality improvement activities to achieve program outcomes.