Prior Authorization Nurse - Remote - AZ

Blue Cross Blue Shield of Arizona • Tampa, FL

84d

About The Position

Under the direction of the Prior Authorization Management (PA), ensures prospective review/prior authorization requests are completed in a timely fashion to meet contractual requirements and ensures all reviews are conducted using nationally recognized and evidence-based standards.

Requirements

• 2 years of clinical experience.
• 1 year of Medicaid/Medicare experience.
• 1 year of experience managing multiple projects.
• Associate degree in Nursing.
• Active, current, and unrestricted license to practice in the State of Arizona as a health professional, including RN or LPN.

Nice To Haves

• 1 year of experience in managed care.
• 1 year of experience in prior authorization/utilization review.
• Bachelor's Degree in Nursing.

Responsibilities

• Ensures prior authorization requests are completed accurately, thoroughly, and in a timely fashion to meet contractual requirements.
• Coordinates and follows the established preauthorization review process for pre-service requests.
• Ensures all reviews are conducted using nationally recognized and evidence-based standards.
• Utilize clinical skills, chart review, physician communication and appropriate criteria for approval of pre-service requests; escalate pre-service request to the Medical Director for determination when criteria is not met.
• Clearly define and document review rationale to support approval, Medical Director Review and/or Notice of Action document.
• Initiates interdepartmental coordination to ensure quality and timely care for members.
• Participates in Quality Improvement Projects as directed.
• Assists the management team and others in preparation for audits and other regulatory activities.
• Assists with other departments and special projects as needed.
• Performs audits of case files and staff documentation as directed.
• Assists with orientation and training of all staff.
• Assists with annual criteria review.
• Assists with implementation of process changes as needed.
• Perform all other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree
• Number of Employees: 1,001-5,000 employees